A nurse is preparing a patient for chest tube insertion. Which of the following nursing actions should the nurse take during the preparation process?

Choice A rationale:

Obtaining cultures from the chest tube site before insertion is not a standard nursing action during chest tube preparation. Cultures are usually taken if there is an infection or concern after the insertion.

Choice B rationale:

Applying a pressure dressing to the wound site after chest tube insertion is not a recommended practice. Airtight dressing can lead to tension pneumothorax. Instead, a sterile occlusive dressing is typically applied.

Choice C rationale:

Administering antibiotics to the patient before the procedure is not a standard nursing action during chest tube preparation. Antibiotics are usually prescribed if there is an infection after the insertion.

Choice D rationale:

Monitoring vital signs and pain level after chest tube insertion is essential to assess the patient's response to the procedure and to identify any complications, such as pneumothorax, bleeding, or infection.

Choice E rationale:

Instructing the patient to take deep breaths during the insertion is not appropriate because chest tube insertion is a sterile procedure, and patients are usually not conscious during the process. The insertion site is anesthetized, and deep breaths could compromise sterile technique and increase the risk of infection.

Choice A rationale:

Applying a pressure dressing to the wound site is not the priority intervention for a chest tube with signs of infection. The primary concern is to address the infection and prevent its spread.

Choice B rationale:

The nurse should prioritize obtaining cultures from the chest tube site to identify the causative organism responsible for the infection. This information will guide the selection of appropriate antibiotics to treat the infection effectively.

Choice C rationale:

Administering oxygen to improve ventilation may be beneficial for some patients, but it does not address the underlying infection. Oxygen therapy can support respiratory function but is not the priority intervention in this situation.

Choice D rationale:

Monitoring vital signs and oxygen saturation is essential but does not address the infection directly. Vital sign monitoring is ongoing, while obtaining cultures is a specific intervention targeted at the suspected infection.