A multidisciplinary team is preparing to remove a pleural chest tube from a client whose lung has fully re-expanded. As the nurse assisting with the procedure, arrange the following actions in the correct chronological sequence to minimize the risk of complications. All options must be used.
- 1Administer a prescribed systemic analgesic to the client.
- 2Instruct the client to take a deep breath, hold it, and bear down.
- 3Apply an occlusive petroleum gauze dressing to the insertion site.
- 4Auscultate bilateral lung sounds and monitor respiratory status.
- 5Facilitate a portable chest radiograph.
Answer
The correct chronological sequence is to premedicate the client, instruct them to perform the Valsalva maneuver during removal, apply an occlusive dressing immediately, perform a clinical respiratory assessment, and finally obtain a verifying radiograph.
The primary goal during chest tube removal is preventing air from re-entering the pleural space while minimizing client discomfort. Analgesia is administered first to allow the medication to take effect. During the actual removal, the Valsalva maneuver (bearing down) ensures positive intrathoracic pressure, pushing air outward rather than pulling it in. The moment the tube exits, an occlusive petroleum dressing is applied to seal the tract. Only after the insertion site is physically secured does the nurse assess clinical respiratory status, which is then followed by a radiograph for definitive confirmation of lung expansion.
Step-by-Step Solution
Key Concept
Safety Protocols for Chest Tube Removal