The nurse is called to a client's room to assist the client who has a chest tube. The client states that it felt like the tube pulled out. The nurse assesses the client and finds that the tube has dislodged and is lying on the floor. What action should the nurse take first?

1. A

   Obtain a pair of sterile gloves

2. B

   Immediately Contact the health care provider

3. C

   Cover the insertion site with a sterile dressing

4. D

   Submerge the dislodged tube into sterile water

Appeared in: JIPMER Pondicherry NO - 2022

Explanation

• The immediate priority in chest tube dislodgement is to prevent air from entering the pleural space, which can cause a tension pneumothorax, a life-threatening condition.
• Covering the insertion site with a sterile, occlusive dressing immediately seals the opening, preventing air entry during inspiration.
• This action directly addresses the most immediate threat to the patient's life, making it the correct first step before any other action.
• Taping the dressing on three sides is the standard of care, as it creates a flutter valve that allows trapped air to escape but prevents atmospheric air from entering.

Why Other Options Were Wrong

• Option A: Obtaining gloves, while important for infection control, is not the first priority. The immediate life-threatening risk of a tension pneumothorax must be addressed first. Delaying covering the wound to get gloves is inappropriate.
• Option B: Contacting the provider is a crucial step, but it is not the first action. The nurse must intervene immediately to stabilize the patient and prevent harm. The call can be made after the site is secured.
• Option D: This action is for a different complication. Submerging the tube in sterile water is the correct response if the chest tube becomes disconnected from the drainage unit, not if the tube is pulled out of the patient's chest.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Emergency management of chest tube dislodgement to guide bedside assessment, documentation, and the next nursing action.
• A dislodged chest tube is a medical emergency. The nurse's prompt and correct action can prevent a tension pneumothorax and save the patient's life.
• Nurses must ensure that emergency supplies, including sterile occlusive dressings (like petroleum gauze) and tape, are kept at the bedside of any patient with a chest tube.
• What if? If the nurse taped all four sides of the dressing, it would create a completely occlusive seal. This is dangerous because if there is still an air leak from the lung, air can accumulate in the pleural space with no way to escape, quickly leading to a tension pneumothorax.

How to Approach the Question

• First, identify the core problem: a dislodged chest tube creates an open wound into the chest.
• Recognize this as a priority-setting question asking for the 'first' action. Use the ABCs (Airway, Breathing, Circulation) framework. A dislodged chest tube is a critical 'Breathing' problem.
• Evaluate each option based on its ability to address the immediate life threat. The primary threat is air entering the pleural space.
• Option A (gloves) and B (calling HCP) are secondary actions. Option D (submerging tube) is for a different problem (disconnection).
• Conclude that covering the site (Option C) is the only action that directly and immediately mitigates the life-threatening risk of a tension pneumothorax.

Concept Tested & Keywords

• Concept Tested: Emergency management of chest tube dislodgement.
• Stem keywords: chest tube, dislodged, pulled out, first action
• Lead-in keywords: first
• Clinical cues: The question asks for the 'first' action, indicating a priority-setting question.

Question ID

QIGtRVqurl7MX3DJSQZlyV

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 32-34