What is the first action the nurse should take with the accidental dislodgement of a chest tube?

Call for the rapid response team and request a portable chest x-ray

Turn the suction drainage system off and auscultate breath sounds

Apply a sterile dressing and tape on three sides

Notify the healthcare provider immediately.

Answer and Explanation

The Correct Answer is C

A. Call for the rapid response team and request a portable chest x-ray: While it is important to call for help and obtain imaging if needed, the immediate action is to address the potential pneumothorax by sealing the wound. The rapid response team and chest x-ray are necessary for further assessment, but securing the wound is the priority in the moment.

B. Turn the suction drainage system off and auscultate breath sounds: Turning off the suction drainage system and auscultating breath sounds may be part of subsequent assessment and care, but these actions are secondary to stopping the entry of air into the pleural space. Auscultating breath sounds would be important after the chest tube is secured to assess for signs of pneumothorax or other complications, but it is not the first priority.

C. Apply a sterile dressing and tape on three sides: The first priority when a chest tube becomes accidentally dislodged is to seal the wound to prevent air from entering the pleural space, which could cause a pneumothorax (collapsed lung). The correct method to seal the chest tube insertion site is to apply a sterile dressing and tape it on three sides. This technique allows air to escape from the pleural space but prevents air from entering, creating a temporary "one-way valve" effect. This is crucial in stabilizing the patient until further medical intervention can be provided. The fourth side of the dressing is left open to allow for air to escape, which helps prevent a tension pneumothorax

D. Notify the healthcare provider immediately: While notifying the healthcare provider is important, securing the wound to prevent further air entry is the immediate priority. Notifying the provider can occur after the dressing is applied. Prompt action to stabilize the chest tube site is crucial to prevent further respiratory distress or complications.

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Correct Answer is C

Explanation

A) Assess for conjunctival bleeding
Conjunctival bleeding refers to blood in the white part of the eye (the conjunctiva), which is typically associated with trauma, infections, or certain blood disorders, but it is not a common cause of diplopia (double vision). Diplopia in multiple sclerosis (MS) is more often due to nerve damage affecting the eye muscles or the pathways controlling eye movement. Therefore, assessing for conjunctival bleeding is not a priority intervention for a client with diplopia related to MS.

B) Encourage the use of sunglasses when outside
While wearing sunglasses may help alleviate light sensitivity, which is a common symptom in individuals with MS, it is not the most appropriate intervention for treating diplopia itself. Diplopia is typically caused by issues with eye muscle control or coordination, often related to the central nervous system. Therefore, while sunglasses might provide comfort, they do not address the underlying cause of the double vision.

C) Alternate the use of an eye patch on each eye
Alternating the use of an eye patch on each eye is an effective intervention for managing diplopia, especially when the cause is related to misalignment or weakness of the eye muscles. The eye patch works by covering one eye at a time to prevent double vision. In MS, this technique can help reduce the visual disturbance and provide relief until further interventions (such as eye exercises or medications) can be considered. This approach is commonly used to manage diplopia caused by nerve involvement affecting ocular muscle function.

D) Apply cool compresses for pain relief
Cool compresses may provide relief for eye irritation or inflammation, but they are not typically used to treat diplopia. Diplopia in MS is more related to neuromuscular dysfunction or nerve damage, rather than acute inflammation or irritation of the eye. Therefore, while a cool compress may offer temporary relief for other symptoms, it is not a targeted solution for double vision in this context.

A. Suction the client as needed B. Administer pantoprazole sodium IV C. Apply sequential compression device (SCD) D. Perform oral care with chlorhexidine

Correct Answer is A

Explanation

A. Suction the client as needed: Suctioning is an essential nursing intervention for clients on mechanical ventilation to maintain effective ventilation. Ventilated clients are at risk for accumulating secretions in the airway, which can obstruct the endotracheal tube or tracheostomy, impairing ventilation and oxygenation. Regular or as-needed suctioning helps to clear secretions, ensuring that the airway remains patent and effective ventilation is maintained. This intervention directly supports the goal of maintaining optimal respiratory function and preventing complications such as atelectasis, pneumonia, or hypoxia.

B. Administer pantoprazole sodium IV: Pantoprazole is a proton pump inhibitor used to decrease stomach acid, typically to prevent stress ulcers in critically ill patients. While this is an important aspect of care for preventing gastrointestinal complications in ventilated patients, it does not directly support ventilation. Therefore, administering pantoprazole is not as directly related to ensuring effective ventilation as suctioning or other respiratory interventions.

C. Apply sequential compression device (SCD): While applying an SCD is important for preventing deep vein thrombosis (DVT) and promoting circulation in immobile patients, it does not directly address the client's ventilation or respiratory function. This intervention is more relevant for preventing venous thromboembolism, not for managing ventilation or airway clearance.

D. Perform oral care with chlorhexidine: Oral care with chlorhexidine is an important practice to reduce the risk of ventilator-associated pneumonia (VAP) and promote overall oral hygiene. It helps decrease the colonization of bacteria in the mouth and reduces the risk of infection. However, while oral care is an essential component of care for a ventilated patient, suctioning directly addresses the goal of effective ventilation by maintaining airway patency, making it the most immediate and relevant intervention for supporting ventilation.

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What is the first action the nurse should take with the accidental dislodgement of a chest tube?

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Naxlex Comprehensive Predictor Exams

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