A nurse is caring for a patient with a chest tube. Accidentally the tube got disconnected. What will the nurs… - SCTIMST Staff Nurse - 2015 (Set-B)

SCTIMST Staff Nurse - 2015 (Set-B)

Medical & Surgical Nursing

Hard

Appeared in: SCTIMST Staff Nurse - 2015 (Set-B)

Explanation

The primary goal is to prevent air from entering the pleural space, which can lead to a pneumothorax or a life-threatening tension pneumothorax.
Submerging the end of the disconnected tube in sterile water immediately creates a temporary water seal.
This action allows air to bubble out from the pleural space but prevents atmospheric air from being drawn back in during inspiration.
It is the quickest and most effective first step to stabilize the patient while preparing for a permanent solution.

Option A: Calling the physician is a necessary step but not the immediate priority. The nurse must first perform a direct intervention to prevent a life-threatening complication.
Option C: Replacing the entire system takes time to gather supplies and set up. Leaving the tube open to air during this period is dangerous.
Option D: This action is indicated for a different emergency: when the chest tube is accidentally pulled out of the patient's chest wall. It is ineffective for a tubing disconnection.

Clinical Relevance

Nursing practice connection: Use the key finding related to Emergency Management of Chest Tube Complications to guide bedside assessment, documentation, and the next nursing action.
A disconnected chest tube is a medical emergency. Failure to act quickly and correctly can lead to a tension pneumothorax, causing respiratory and cardiovascular collapse.
Nursing protocols require that emergency supplies, including a bottle of sterile water, sterile dressings, and rubber-tipped clamps, be kept at the bedside of any patient with a chest tube.
What if? If the chest tube were accidentally pulled completely out of the patient's chest, the first action would be different. The nurse should immediately apply pressure with a gloved hand and then cover the site with a sterile occlusive dressing taped on only three sides. This allows trapped air to escape but prevents air from entering.

How to Approach the Question

Identify the question type: This is a clinical scenario asking for the first nursing action, which indicates a priority question.
Analyze the scenario: A chest tube has disconnected from the drainage system. The core problem is a break in the closed system, creating a direct path for air to enter the pleural space.
Evaluate the immediate risk: The greatest and most immediate risk is air entering the pleural space during inspiration, leading to a pneumothorax or tension pneumothorax.
Review the options based on the immediate risk: Which action most quickly and effectively stops air from entering the pleural space?
Option A (Call MD) is indirect and delayed. Option C (Replace system) takes time. Option D (Dressing) is for the wrong problem (dislodgement from chest).
Select the best option: Placing the tube in sterile water (Option B) is a direct, immediate intervention that re-establishes a one-way seal, directly addressing the life-threatening risk.

Concept Tested & Keywords

QuItChTbf0qA9qz3gSg0Um

E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 35-37

E6 Nursing Fundamentals Taylor p. 734-736