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Question

Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is assisting a client who has a right-sided chest tube to change positions in bed. Suddenly, the chest tube is completely pulled out of the client's chest wall. Arrange the following immediate nursing actions in the correct chronological order.

  1. 1Instruct the client to forcefully exhale and bear down.
  2. 2Cover the insertion site with a sterile petroleum gauze.
  3. 3Secure the occlusive dressing with tape on three sides.
  4. 4Assess the client's respiratory rate and oxygen saturation.
  5. 5Notify the registered nurse and healthcare provider.

Answer

The correct sequence is to first instruct the client to exhale and bear down, cover the site with petroleum gauze, secure the tape on three sides, assess the respiratory status, and finally notify the healthcare team.
In any respiratory emergency where the pleural space is exposed to the atmosphere, the absolute first priority is to stop air entry (Airway/Breathing principle). Asking the client to exhale and bear down provides an immediate internal pressure block, allowing the nurse a few seconds to apply the physical petroleum gauze seal. Taping it on three sides is the standard of care to create a one-way flutter valve. Only after securing the airway and breathing mechanics should the nurse assess the physiological response and notify the team.

Step-by-Step Solution

1
Instruct the client to forcefully exhale and bear down.
Intrathoracic pressure immediately increases.
This prevents atmospheric air from entering the pleural cavity through the newly opened wound, which would collapse the lung.
2
Cover the insertion site with a sterile petroleum gauze.
An airtight seal is created over the wound.
The petroleum gauze acts as an immediate physical barrier to stop further air exchange between the atmosphere and the pleural space.
3
Secure the occlusive dressing with tape on three sides.
A flutter valve (one-way valve) is established.
Taping only three sides allows any trapped air to escape during exhalation but prevents outside air from being drawn in during inhalation, drastically reducing the risk of a tension pneumothorax.
4
Assess the client's respiratory rate and oxygen saturation.
Baseline respiratory data is obtained.
The nurse must evaluate if the client is experiencing respiratory distress, hypoxia, or signs of a developing pneumothorax after the acute intervention is applied.
5
Notify the registered nurse and healthcare provider.
The medical team is alerted to the critical event.
The client will likely require emergency medical intervention, such as a chest X-ray and the insertion of a new chest tube.

Key Concept

Emergency Priority Management of an Accidentally Dislodged Chest Tube
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Topics

Physiological Adaptation

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