A nurse is caring for a child who has a chest tube. After ambulating and returning the child to bed, the nurse notes that the child has dyspnea and decreasing oxygen saturation readings. Which nursing action is the priority?
A.
Assess the tubing for kinks.
B.
Call the rapid response team.
C.
Facilitate a portable chest x-ray.
D.
Provide bag-valve-mask breathing.
ANS: A
In order to function properly, the chest tube system should be at least 1 ft below the level of the lungs, and the tubing must be free of kinks. After positioning the child in bed, the potential for kinking the tubing is fairly high, so the nurse should quickly assess the tubing before taking any other actions. If the system is working, other interventions need to occur, including calling the rapid response team.
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