What action should be taken if a nurse identifies that the chest tube is not draining fluid, but the tubing is clear?

• A. Reposition the client
• B. Notify the surgeon immediately
• C. Continue to monitor
• D. Attempt to strip the chest tube

Answer: (C)

When a nurse identifies that a chest tube is not draining fluid but the tubing is clear, the most appropriate action is to continue monitoring. This choice reflects an understanding that several factors can temporarily affect drainage, such as patient position, respiratory effort, or potential clots in the tube that may not be immediately visible.

Continuing to monitor allows the nurse to observe for any changes in the patient's condition or output, which may help determine if the situation resolves itself or if further intervention is needed. This approach encourages vigilant nursing care while avoiding premature actions that might not be warranted right away.

Repositioning the client can sometimes aid in drainage but is typically done as a part of ongoing monitoring rather than as the first response. Notifying the surgeon immediately may be overly aggressive unless there are signs of complications, such as patient distress or changing vital signs. Attempting to strip the chest tube can be risky and is generally not recommended as it could create further complications, such as creating a pressure change or dislodging the tube. Thus, monitoring remains the best initial step to assess the situation accurately before taking more invasive measures.