While turning a client with a chest tube, the drainage system disconnects from the chest tube tubing. Which action should the nurse take first?
1Strip the tubing to remove possible clots.
2Place the distal end of the chest tube tubing in sterile water.✓ Correct answer
3Raise the drainage system above the level of the chest.
4Clamp the chest tube for the rest of the shift.
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.
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 Practice GuideOpen RN advanced skills guidance describes using sterile water or saline to create a temporary water seal if tubing becomes disconnected from the drainage system.
CautionDifferentiate disconnection from accidental tube removal; tube removal requires an occlusive dressing and provider notification.
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.