A nurse is caring for a client with a chest tube. Which action should the nurse take?

Choice A Reason:

“Call the provider” is important but not the first priority. The immediate concern is to maintain the client’s intravenous access to ensure they can receive any necessary medications or fluids promptly. Once the line is secured, the provider should be notified to receive further instructions and manage the client’s condition.

Choice B Reason:

“Notify the blood bank” is also crucial but comes after ensuring the client’s immediate safety. The blood bank needs to be informed to investigate the cause of the reaction and prevent further issues, but this step follows the initial emergency interventions.

Choice C Reason:

“Collect a urine specimen” is necessary to check for hemolysis, which can occur during a transfusion reaction. However, this is not the first step. The priority is to stabilize the client by maintaining IV access with normal saline.

Choice D Reason:

“Keep the line open with 0.9% NS through new tubing” is the correct first intervention. This action ensures that the client remains hydrated and that the IV line is available for any emergency medications or treatments. Using new tubing prevents any contamination from the transfusion set.

Choice A Reason:

Keep the drainage system below the level of the client’s chest at all times is correct. This measure ensures that gravity assists in the drainage of air and fluid from the pleural space, preventing backflow into the chest cavity. Keeping the drainage system below chest level maintains the negative pressure needed for effective drainage.

Choice B Reason:

Clamp the chest tube prior to transferring the client to a wheelchair is incorrect. Clamping the chest tube can lead to a buildup of air or fluid in the pleural space, potentially causing a tension pneumothorax. The chest tube should remain unclamped to allow continuous drainage.

Choice C Reason:

Empty the collection chamber prior to transport is incorrect. While it is important to monitor and manage the drainage, emptying the collection chamber is not necessary before transport. The focus should be on maintaining the integrity and function of the drainage system.

Choice D Reason:

Disconnect the chest tube from the drainage system during transport is incorrect. Disconnecting the chest tube can lead to a loss of the negative pressure system, resulting in potential complications such as pneumothorax. The chest tube should remain connected to ensure continuous drainage and maintain the negative pressure.