Fundamentals of Nursing Q 310
While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by Nurse Flora is most appropriate?
A. Assist the client to ambulate back to bed.
B. Reconnect the tube to the water seal.
C. Assess the client's lung sounds with a stethoscope.
D. Have the client cough forcibly several times.
Correct Answer: B. Reconnect the tube to the water seal.
The tube should be reconnected to the water seal as quickly as possible. Assisting the client back to bed and assessing the client’s lung are possible actions after the system is reconnected. Or place the end of the tube in a bottle of sterile water, creating a water seal. Instruct a colleague to prepare a new sterile chest-drainage collection device, or retrieve a new sterile connector while safely returning the patient to bed. Observe the patient for signs and symptoms of respiratory decline. Then reconnect the chest tube to the new drain and unclamp it.
Option A: If walking with the patient and the chest tube becomes dislodged where it connects to the drainage tubing, immediately close off the tubing to air with a gloved hand by crimping it or using a clamp, if readily available.
Option C: Whether chest-tube removal was planned or unplanned, monitor the patient closely for signs and symptoms of respiratory compromise, using such techniques as pulse oximetry (Spo2), end-tidal carbon dioxide (ETco2) monitoring, and breath sound auscultation.
Option D: Monitor the patient’s respiratory rate and effort. A repeat chest X-ray (if indicated) may be done to compare to previous films and evaluate for presence or return of a pneumothorax, an effusion, or other problem.