Nurse observes fluctuation in water seal chamber of chest drain. What should be done?

Correct option is B

Fluctuation (tidaling) in the water seal chamber is a normal finding that reflects changes in pleural pressure during breathing. However, continuous bubbling may indicate an air leak. Therefore, the nurse should assess for an air leak to determine if it is from the patient’s lung or from the chest drainage system connections.

(a) Unkinking for an air leak — Incorrect ()
Unkinking is done when there is an absence of fluctuation, which indicates a blockage or obstruction in the tubing. Since fluctuation is already present, the tube is patent and unkinking is not required. Hence, this is not the appropriate intervention here.

(b) Assessing for an air leak — Correct ()
The nurse should immediately assess for an air leak when fluctuations are observed, especially if continuous bubbling is present. Assessing helps identify whether the leak is from the lung tissue or due to a loose connection in the drainage system. This is the priority nursing action.

(c) Documenting that the lung has re-expanded — Incorrect ()
Fluctuation indicates that the lung is still expanding and the pleural space is not fully sealed. Lung re-expansion is confirmed when fluctuation ceases. Therefore, documenting re-expansion at this point is incorrect.

(d) Documenting that the lung has not yet re-expanded — Incorrect ()
While fluctuation may suggest incomplete lung expansion, the nurse should not document this conclusion without assessing for air leaks first. Documentation is secondary; the immediate step is a clinical assessment.