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NCLEX-RN · Question #581

A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:

The correct answer is C. Apply a petrolatum dressing over the site. (A) This action is inappropriate. Coughing will not re-expand the lung and could result in further (B) This action is a medical procedure, not a nursing procedure. (C) An occlusive dressing will prevent further air leak until the physician institutes further (D) The decision to…

Physiological Integrity: Reduction of Risk Potential

Question

A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:

Options

  • AInstruct the client to cough deeply to re-expand her lung
  • BPut on sterile gloves and replace the tube
  • CApply a petrolatum dressing over the site
  • DAuscultate the lung to determine if she needs the tube replaced

How the community answered

(45 responses)
  • A
    9% (4)
  • B
    2% (1)
  • C
    84% (38)
  • D
    4% (2)

Explanation

(A) This action is inappropriate. Coughing will not re-expand the lung and could result in further (B) This action is a medical procedure, not a nursing procedure. (C) An occlusive dressing will prevent further air leak until the physician institutes further (D) The decision to reinsert the tube is a medical decision, not a nursing one.

Topics

#chest tube#occlusive dressing#pneumothorax#emergency intervention

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