The nurse is caring for a client with a chest tube that has accidentally dislodged. Which of the following would be appropriate actions for the nurse to take? (Select all that apply.)
a. Notify the physician.
b. Notify the client's family.
c. Cover the opening with a sterile dressing.
d. Cover the opening with petrolatum gauze.
e. Quickly reinsert the tube to prevent lung collapse.
f. Monitor for dyspnea.
A, D, F
Assessment for a client with a chest tube, if accidentally dislodged, should include covering the opening with petrolatum gauze, taping only three sides of the dressing to create a one-way valve in which air can exit, monitoring for dyspnea, and notifying the physician.
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