The nurse notes that the client's chest tube pulled out by 2 inches during turning and repositioning. Which does the nurse implement?

Question

1. Instruct the nursing assistant to apply pressure for 5 minutes.
2. Replace the WSD system with a sterile waterless unit quickly.
3. Hold a towel firmly over site and send for petrolatum gauze.
4. Push tube into place and apply an occlusive sterile dressing.

Answer 1

3
3. The nurse secures the tube in place with a clean towel and sends the nursing assis-tant for sterile petroleum gauze. The nurse securely wraps the gauze around the base of the chest tube insertion to recreate an airtight seal so negative intrapleural pressure can be restored. The nurse should collaborate with the provider for a chest x-ray to evaluate the lung's status after the accident.
1. The nurse applies pressure to the site to prevent the wound from drawing in room air because this intervention requires clinical judgment and critical thinking to seal the wound completely. The nursing assistant receives training to procure the petroleum gauze for the nurse.
2. A standard or a waterless system is suitable for the client's WSD; however, neither system is effective therapy until the airtight insertion site is reestablished.
4. The nurse avoids pushing the chest tube into place because the tubing pulled out by the accident is contaminated; if reinserted into the chest, the client is at high risk for a pulmonary infection.