Saunders Respiratory Practice

What is the immediate action the nurse should take after a chest tube is accidentally dislodged from the chest?

1. Call for help immediately

2. Apply sterile gauze over the chest tube insertion site

3. Reattach the chest tube quickly

4. Administer oxygen to the client

The correct answer is: Apply sterile gauze over the chest tube insertion site

Applying sterile gauze over the chest tube insertion site is the immediate action the nurse should take after a chest tube is accidentally dislodged. This step is crucial to prevent air from entering the pleural space, which can lead to a pneumothorax, a condition that can cause severe respiratory distress. By covering the site with sterile gauze, the nurse is providing a barrier that helps to prevent further complications while also facilitating the safe management of the situation until additional assistance can be obtained. In an emergency scenario involving a dislodged chest tube, applying a dressing is a priority to ensure the client’s safety. While calling for help is also important, the immediate focus should be on addressing the open wound to mitigate potential risks. Quickly reattaching the chest tube or administering oxygen may be necessary actions, but they are not the first steps. The intervention of covering the insertion site takes precedence to stabilize the situation.