What is the first action the nurse should take with the accidental dislodgement of a chest tube?

Call for the rapid response team and request a portable chest x-ray

Turn the suction drainage system off and auscultate breath sounds

Apply a sterile dressing and tape on three sides

Notify the healthcare provider immediately.

Answer and Explanation

The Correct Answer is C

A. Call for the rapid response team and request a portable chest x-ray: While it is important to call for help and obtain imaging if needed, the immediate action is to address the potential pneumothorax by sealing the wound. The rapid response team and chest x-ray are necessary for further assessment, but securing the wound is the priority in the moment.

B. Turn the suction drainage system off and auscultate breath sounds: Turning off the suction drainage system and auscultating breath sounds may be part of subsequent assessment and care, but these actions are secondary to stopping the entry of air into the pleural space. Auscultating breath sounds would be important after the chest tube is secured to assess for signs of pneumothorax or other complications, but it is not the first priority.

C. Apply a sterile dressing and tape on three sides: The first priority when a chest tube becomes accidentally dislodged is to seal the wound to prevent air from entering the pleural space, which could cause a pneumothorax (collapsed lung). The correct method to seal the chest tube insertion site is to apply a sterile dressing and tape it on three sides. This technique allows air to escape from the pleural space but prevents air from entering, creating a temporary "one-way valve" effect. This is crucial in stabilizing the patient until further medical intervention can be provided. The fourth side of the dressing is left open to allow for air to escape, which helps prevent a tension pneumothorax

D. Notify the healthcare provider immediately: While notifying the healthcare provider is important, securing the wound to prevent further air entry is the immediate priority. Notifying the provider can occur after the dressing is applied. Prompt action to stabilize the chest tube site is crucial to prevent further respiratory distress or complications.

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Correct Answer is C

Explanation

A. Dextromethorphan 10 mg PO q 4 hr: Dextromethorphan is a cough suppressant, and while it may be useful for controlling a dry, non-productive cough, it is not appropriate for ineffective airway clearance in pneumonia. In fact, suppressing the cough in pneumonia could prevent the patient from clearing mucus from the airways, exacerbating the problem. It is more appropriate for a client who has a dry cough without significant mucus production.

B. Cromolyn MDI 2 puffs daily: Cromolyn is a mast cell stabilizer used for the prevention of asthma and allergy symptoms, and it is not typically used for treating pneumonia or ineffective airway clearance. It works by preventing the release of inflammatory mediators in response to allergens, but it does not address the issue of clearing mucus in the airways during a bacterial infection like pneumonia.

C. Guaifenesin 200 mg PO q 4 hr: Guaifenesin is an expectorant that helps loosen and thin mucus in the airways, making it easier for the client to cough up and clear secretions. This is the most appropriate medication for addressing ineffective airway clearance in a client with pneumonia, as the goal is to facilitate the removal of mucus and improve respiratory function. Guaifenesin does not suppress the cough reflex but instead promotes productive coughing, which is essential for clearing the airways during a respiratory infection like pneumonia.

D. Methylprednisolone 30 mg IV BID: Methylprednisolone is a corticosteroid used to reduce inflammation and control severe allergic or inflammatory conditions. While corticosteroids may be used in certain cases of pneumonia (e.g., in cases of significant inflammation or an underlying condition like COPD), they are not the first-line treatment for ineffective airway clearance. The priority in this case is to promote mucus clearance, which is better addressed by guaifenesin.

A. pH 7,44; Pa02 44 mmHg: PaCO2 35 mmHg; HCO3 25 mEq/L; 02 Sat 76% B. pH 7.30; Pa02 80 mmHg; PaCO2 62 mmHg; HCO3 25 mEq/L; 02 Sat 94% C. pH 7.35; Pa02 65 mmHg; PaCO2 40 mmHg: HCO3 26 mEq/L; 02 Sat 90% D. PH 7.48; Pa02 75 mmHg; PaCO2 41 mmHg: HCO3 28 mEg/L; 02 Sat 9386

Correct Answer is A

Explanation

A. pH 7.44; PaO2 44 mmHg; PaCO2 35 mmHg; HCO3 25 mEq/L; O2 Sat 76%: This set of arterial blood gas (ABG) values is consistent with hypoxemic respiratory failure. Hypoxemic respiratory failure is characterized by a PaO2 less than 60 mmHg, and this client has a PaO2 of 44 mmHg, which is significantly below the normal range of 80-95 mmHg. Despite the fact that the client is on a 100% non-rebreather mask (which should ideally deliver high levels of oxygen), the low PaO2 suggests that oxygenation is not being effectively improved. Additionally, the low O2 saturation of 76% further supports the diagnosis of hypoxemic respiratory failure.

B. pH 7.30; PaO2 80 mmHg; PaCO2 62 mmHg; HCO3 25 mEq/L; O2 Sat 94%: This ABG indicates respiratory acidosis (pH is low, PaCO2 is elevated), but the PaO2 of 80 mmHg is within the normal range, and the O2 saturation of 94% is also normal. Respiratory acidosis with a normal PaO2 would indicate an issue with ventilation (hypoventilation), not hypoxemic respiratory failure. The patient is retaining CO2 but is still oxygenating well, so this result does not indicate hypoxemic respiratory failure.

C. pH 7.35; PaO2 65 mmHg; PaCO2 40 mmHg; HCO3 26 mEq/L; O2 Sat 90%: This result shows a PaO2 of 65 mmHg, which is mildly low but not sufficiently low to meet the criteria for hypoxemic respiratory failure (PaO2 should be below 60 mmHg for this diagnosis). The O2 saturation of 90% is also slightly low but not critically low. This client may have mild hypoxia but is not in respiratory failure based on these values.

D. pH 7.48; PaO2 75 mmHg; PaCO2 41 mmHg; HCO3 28 mEq/L; O2 Sat 93%: In this case, the PaO2 of 75 mmHg is slightly low but still within an acceptable range, and the O2 saturation of 93% is adequate. The elevated pH and normal PaCO2 suggest the presence of respiratory alkalosis (likely caused by hyperventilation). These ABG results are not consistent with hypoxemic respiratory failure, as the oxygen levels are still within a safe range.

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Arterial Blood Gases
pH	7.35-7.45
PaCO2	35-45mmHg
PaO2	80-100mmHg
HCO3-	22-26 mEq/L
O2 Saturation	>95%
Chemistry
BUN	8-21mg/dl
Creatinine	0.5-1.2mg/dl
Na	135-145 mEq/L
K	3.5-5.3 mEq/L
Cl	97-107 mEq/L
CO2	22-26 mEq/L
Ca	8.2-10.2 mg/dl
Glucose	65-99 mg/dl
Mg	1.7-2.2 mg/dl
PO4	2.5-4.5 mg/dl

What is the first action the nurse should take with the accidental dislodgement of a chest tube?

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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