A nurse is preparing to remove a chest tube from a patient. Which of the following actions should the nurse take during the removal procedure? Select all that apply:

Choice A rationale:

Keeping the drainage system above the chest level is incorrect because the drainage system should be placed below the chest level to facilitate proper drainage of fluids and air.

Choice B rationale:

Clamping the tubing for an extended period to prevent leaks is incorrect. Chest tubes should never be clamped for an extended period as it can lead to a dangerous buildup of pressure within the pleural space and impair proper drainage.

Choice C rationale:

Ensuring adequate and stable water levels in the water-seal and suction-control chambers is correct. Maintaining appropriate water levels is essential for maintaining the proper functioning of the chest tube system, ensuring that it can effectively remove air and fluid from the pleural space.

Choice D rationale:

Milking or stripping the tubing regularly to enhance drainage is incorrect. This practice is outdated and can cause damage to the chest tube, leading to potential complications. The tubing should not be manipulated in this manner.

Choice E rationale:

Keeping the tubing free of kinks, loops, or dependent areas is correct. Any kinks, loops, or dependent areas can obstruct the flow of fluids and air within the chest tube system, impairing its functionality.

Choice A rationale:

The nurse should obtain a physician's order and informed consent from the patient before removing the chest tube. Rationale: Chest tube removal is a medical procedure that requires a physician's order, and obtaining informed consent ensures that the patient is aware of the procedure and its potential risks.

Choice B rationale:

Instructing the patient to exhale forcefully during the removal is not necessary and may even be harmful. Rationale: The Valsalva maneuver, which involves forceful exhalation, can increase intrathoracic pressure and may lead to complications like pneumothorax during chest tube removal. Therefore, this action should be avoided.

Choice C rationale:

Monitoring the patient's respiratory status and vital signs after the removal is essential. Rationale: After chest tube removal, it is crucial to monitor the patient for signs of respiratory distress, such as shortness of breath or decreased oxygen saturation, and vital signs to detect any complications promptly.

Choice D rationale:

Applying an occlusive dressing with petroleum gauze over the wound site after removal is not the standard practice. Rationale: After chest tube removal, the wound site is typically left open to allow for the drainage of any residual air or fluid. Applying an occlusive dressing can trap air or fluid, leading to complications.

Choice E rationale:

Preparing sterile supplies such as a suture removal kit before the procedure is not necessary for chest tube removal. Rationale: Chest tube removal does not require suture removal or sterile supplies. It is a relatively simple procedure that involves removing the chest tube after ensuring proper lung re-expansion and securing the wound with an appropriate dressing.