During a routine dressing change, the nurse accidentally pulls the drain tubing 2 inches out of the insertion site. Place the nursing interventions in the order the nurse should use for subsequent nursing actions
1. Provide wound care and apply dressing.
2. Ask client to describe wound sensations.
3. Swab tubing with chlorhexidine solution.
4. Collaborate with the surgeon immediately.
3, 1, 2, 4
3 and 1. When tubing is advanced from a surgical wound, the surgical team cannot push the tub-ing in a retrograde motion without contaminating the wound, so the nurse cleanses the tubing thoroughly, secures the tubing in place, completes wound care, and applies a fresh dressing to cover the wound.
2. If the tubing slipped out 2 inches spontaneously, the client is unlikely to feel minor discomfort because it indicates tissue had not grown onto the tubing significantly; however, if the nurse ac-cidentally pulled out the tubing, the client is more likely to experience a sharp, burning sensation as the tubing pulls off of regional tissue adhesions. Generally, a few minutes pass before the sensation dissipates.
4. After attending to the client, the drain, the wound, and the dressing, the nurse collaborates with the surgeon to plan follow-up nursing care.
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