Place the nursing actions in order when the patient-side chest tube disconnects from the drainage unit.
Ordered Response
Choose your responses, then check the answer.
Explanation
Create a temporary water seal immediately and summon help, then assess for respiratory compromise. Replace the drainage unit using sterile technique, restore ordered settings, and reassess both the client and the system. Routine prolonged clamping is avoided because trapped pleural air can cause tension pneumothorax.
Correct sequence Temporary water seal → respiratory assessment → obtain replacement → reconnect → reassess and document.
Why this is correct A disconnected patient-side tube can permit air to enter the pleural space. Sterile water or saline provides a temporary one-way seal while assistance and replacement equipment arrive. Client assessment follows immediately because falling oxygen saturation, asymmetric movement, hypotension, or increasing dyspnea may indicate a pneumothorax.
NCLEX decision rule Distinguish a tube disconnected from the drainage unit from a tube pulled out of the chest; the emergency response is different.
Reference
1NCBI Bookshelf: Manage Chest Tube Drainage Systems
Chest-tube system disconnectionThe tube remains secured in the client's chest, but its distal end is no longer connected to the drainage unit. The client is awake and breathing spontaneously. Follow agency policy and the drainage-system manufacturer's instructions.
Water Seal — A one-way liquid barrier that allows pleural air to leave while limiting air entry.
Tension Pneumothorax — Progressive pressure from trapped pleural air that impairs ventilation and circulation.
Air Leak — Bubbling that may indicate air movement in the system.