The nurse is preparing to assist the physician in removal of a chest tube. What should the nurse do to prepare the patient? (Select all that apply.)
a. Assess the patient's need for pain medication.
b. Instruct the patient about the process.
c. Teach the patient to take a deep breath and hold it.
d. Clamp the chest tubes.
A, B, C
The nurse should prepare the patient for chest tube removal by (1) assessing the need for pre-removal analgesia and obtaining the required medication orders, and (2) instructing the patient about the process and what will be requested of the patient. During removal of the chest tube, it is important to instruct the patient to take a deep breath and hold it until the tube is removed. This maneuver prevents air from being sucked into the chest as the tube is pulled out and an occlusive dressing is applied. Although clamping of the chest tubes is done to determine whether the chest tube can be eliminated, this is not part of the immediate chest tube removal procedure.
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