Reduction of Risk Potential Q 87

Correct Answer: C. Cover the insertion site with a Vaseline gauze

If the client pulls the chest tube out of the chest, the nurse’s first action should be to cover the insertion site with an occlusive dressing. Afterward, the nurse should call the doctor, who will order a chest x-ray and possibly reinsert the tube. A chest tube may be inserted at the bedside, in the procedure room, or in the surgical suite. Health care providers often assist physicians in the insertion and removal of a closed chest tube drainage system.

Option A: A chest tube falling out is an emergency. Immediately apply pressure to the chest tube insertion site and apply sterile gauze or place a sterile Jelonet gauze and dry dressing over the insertion site and ensure tight seal. Apply dressing when the patient exhales. If a patient goes into respiratory distress, call a code. Notify primary health care providers to reinsert new chest tube drainage systems.

Option B: A chest tube drainage system disconnecting from the chest tube inside the patient is an emergency. Immediately clamp the tube and place the end of the chest tube in sterile water or NS. The two ends will need to be swabbed with alcohol and reconnected.

Option D: After initial insertion of a chest tube drainage system, assess the patient every 15 minutes to 1 hour. Once the patient is stable, and depending on the condition of the patient and the amount of drainage, monitoring may be less frequent. If the patient is stable (vital signs within normal limits; drainage amount, colour, or consistency is within normal limits; the patient is not experiencing any respiratory distress or pain), assessment may be completed every 4 hours. Always follow hospital policy for frequency of monitoring a patient with a chest tube.