Which instruction should the nurse give a patient who is going to have a chest tube removed?

Appeared in: AIIMS Bhatinda NO - 2019

Explanation

The correct instruction is to ask the patient to take a deep breath and hold it.
This action is also known as the Valsalva maneuver.
Performing the Valsalva maneuver increases the pressure inside the chest (intrathoracic pressure).
This increased pressure prevents atmospheric air from entering the pleural space when the tube is removed.
Preventing air entry is crucial to avoid causing a pneumothorax (collapsed lung).

Option A: Hyperventilation involves rapid breathing, which does not create the sustained increase in intrathoracic pressure needed to prevent air from entering the pleural space.
Option B: Inhaling creates negative pressure within the chest cavity. This would actively pull air from the outside into the pleural space through the insertion site as the tube is removed, causing a pneumothorax.
Option D: This is the opposite of the correct instruction. The Valsalva maneuver is the physiological mechanism that protects the patient from a pneumothorax during chest tube removal.

Clinical Relevance

Nursing practice connection: Use the key finding related to Nursing procedure and patient instruction for chest tube removal to guide bedside assessment, documentation, and the next nursing action.
The nurse's primary role during chest tube removal is to ensure patient safety by preventing complications, the most common of which is an iatrogenic pneumothorax.
Proper patient instruction is a critical nursing intervention that directly impacts the outcome of the procedure.
What if? If the patient is unconscious or unable to follow commands (e.g., a ventilated patient), the chest tube should be removed at the peak of expiration when intrathoracic pressure is highest. For a ventilated patient, this can be timed with the ventilator's expiratory cycle.

How to Approach the Question

First, identify the core procedure: removal of a chest tube.
Recall the primary goal of the procedure: to remove the tube without allowing air to enter the pleural space, which would cause a pneumothorax.
Think about respiratory mechanics. Inhalation creates negative pressure (sucks air in), while exhalation or holding your breath against a closed glottis (Valsalva) creates positive pressure (pushes air out).
Evaluate each option based on its effect on intrathoracic pressure.
Eliminate options that create negative pressure (inhaling) or do not create sustained positive pressure (hyperventilating).
Select the option that actively increases intrathoracic pressure to prevent air entry, which is taking a deep breath and holding it.

Concept Tested & Keywords

Concept Tested: Nursing procedure and patient instruction for chest tube removal.
Stem keywords: chest tube, removed, nurse, instruction
Lead-in keywords: Which
Negative lead-in flag: false

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E6 Nursing Fundamentals Potter Perry 12e Part 5 pp. 2-4, 32-34

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