While turning a client with a chest tube, the drainage syste… | MyMerci
Complications of ProceduresROR
Question
While turning a client with a chest tube, the drainage system disconnects from the chest tube tubing. Which action should the nurse take first?
1Clamp the chest tube for the rest of the shift.
2Strip the tubing to remove possible clots.
3Place the distal end of the chest tube tubing in sterile water.✓ Correct answer
4Raise the drainage system above the level of the chest.
Explanation
A disconnected chest tube system can allow air to enter the pleural space. Placing the distal end of the tubing in sterile water creates a temporary water seal while help and a new drainage system are obtained. Routine clamping, stripping, or raising the drainage system can create harm.
In-depth explanation
Clinical Judgment Restore a water seal quickly to prevent air entry into the pleural space.
Memory Tip Disconnected chest tube: sterile water seal now, replace system next.
KR vs US NCLEX chest tube questions prioritize maintaining the water seal and avoiding unnecessary clamping.
Clinical scenario
Clinical Practice Guide Open RN advanced skills guidance describes using sterile water or saline to create a temporary water seal if tubing becomes disconnected from the drainage system.
Caution Differentiate disconnection from accidental tube removal; tube removal requires an occlusive dressing and provider notification.
Key concepts
Chest Tube — A tube placed in the pleural space to remove air or fluid and support lung expansion.
Water Seal — A one-way seal that lets air leave the pleural space while preventing air from moving back in.
Pleural Space — The space between visceral and parietal pleura where abnormal air or fluid can impair lung expansion.