Saunders Respiratory Practice

When a client with a closed chest tube drainage system accidentally dislodges the tube while transferring to a chair, how should the nurse respond?

1. Call for additional assistance

2. Cover the insertion site with sterile gauze

3. Document the incident immediately

4. Reinsert the tube

The correct answer is: Cover the insertion site with sterile gauze

In the scenario where a client with a closed chest tube drainage system accidentally dislodges the tube, the priority for the nurse is to prevent air from entering the pleural cavity and to manage the insertion site appropriately. Covering the insertion site with sterile gauze is crucial because it helps to seal the area, minimizing the risk of introducing air and preventing further complications such as tension pneumothorax. By applying sterile gauze, the nurse provides immediate protection for the site, which is critical in the management of a dislodged chest tube. This protective measure is essential until further assessment and intervention can be carried out, such as calling the physician or the respiratory therapist for assistance. It is also important for the gauze to be airtight to effectively prevent air from entering the pleural space. Other options, while they have their own importance in a comprehensive response plan, would not address the immediate need for securing the site. For instance, calling for additional assistance is necessary, but it does not directly protect the client. Documenting the incident would be appropriate after ensuring the patient's safety, and reinserting the tube is not within the scope of practice for nurses without an order or appropriate training. The immediate action of covering the site is therefore the most critical in