When entering the room of a patient who has a chest tube attached to a water-seal drainage system, the nurse observes the chest tube is lying on the floor. Which of the following actions should the nurse take first?

Reinsert the tube into the chest tube insertion site

Insert the end of the chest tube in a container of sterile water

Auscultate the lung sounds in bilateral lung fields

Apply a sterile dressing to the chest tube insertion site

Answer and Explanation

The Correct Answer is D

A. Reinsert the tube into the chest tube insertion site: Reinserting a chest tube that has become dislodged is outside the scope of nursing practice and risks introducing infection and causing further trauma. Re-insertion must be performed by a qualified provider using sterile technique under appropriate conditions.

B. Insert the end of the chest tube in a container of sterile water: Placing the end of a dislodged chest tube into sterile water is appropriate only if the tube has disconnected from the drainage system but remains in the patient’s chest. In this scenario, the tube is lying on the floor, indicating it has been removed from the patient, so this action is not appropriate.

C. Auscultate the lung sounds in bilateral lung fields: Assessing lung sounds is important, but it is not the first priority. When a chest tube becomes dislodged from the patient, there is an immediate risk of air entering the pleural space and causing a tension pneumothorax. The insertion site must be addressed before further assessment.

D. Apply a sterile dressing to the chest tube insertion site: The priority is to immediately cover the insertion site with a sterile occlusive dressing (often taped on three sides) to prevent air from entering the pleural cavity and causing a life-threatening tension pneumothorax. This intervention directly addresses the most immediate physiological threat.

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Correct Answer is ["A","B","C","D"]

Explanation

A. Administering high-flow oxygen therapy: Patients with flail chest often experience hypoxemia due to impaired ventilation and paradoxical chest wall movement. Providing high-flow oxygen helps maintain adequate oxygenation and tissue perfusion while reducing the risk of respiratory distress.

B. Administering analgesics for pain relief: Severe pain from rib fractures can inhibit deep breathing and effective coughing, increasing the risk of atelectasis and pneumonia. Adequate analgesia, including opioids or regional blocks, allows the patient to breathe more comfortably and participate in respiratory exercises safely.

C. Encouraging deep breathing and coughing exercises: Respiratory physiotherapy is critical to prevent pulmonary complications such as atelectasis and pneumonia. Even with chest wall instability, guided deep breathing and coughing help mobilize secretions and improve lung expansion while maintaining oxygenation.

D. Prepare for the need for intubation: Severe flail chest can lead to respiratory failure due to inadequate ventilation and hypoxemia. The nurse must anticipate and be prepared for intubation and mechanical ventilation if the patient’s respiratory status deteriorates, ensuring rapid response to acute respiratory compromise.

E. Encouraging the patient to lie flat on their back: Lying flat is contraindicated for flail chest patients because it can exacerbate paradoxical movement of the chest wall, increase respiratory effort, and worsen oxygenation. Elevating the head of the bed or maintaining a semi-Fowler’s position is preferred to facilitate ventilation.

A. Systolic blood pressure increase of 10 mm Hg at completion of ambulation B. Heart rate increase of 10 beats/min at completion of ambulation C. Respiratory rate of 20 during ambulation D. New onset of chest pain 8/10 during ambulation

Correct Answer is D

Explanation

A. Systolic blood pressure increase of 10 mm Hg at completion of ambulation: A mild increase in systolic blood pressure during physical activity is an expected physiological response. This level of change is within acceptable limits and does not contraindicate progression in cardiac rehabilitation.

B. Heart rate increase of 10 beats/min at completion of ambulation: A slight increase in heart rate with activity is normal as the cardiovascular system meets the body’s increased oxygen demand. Such minimal changes do not indicate intolerance to activity or risk during rehabilitation.

C. Respiratory rate of 20 during ambulation: A respiratory rate of 20 breaths per minute is within normal limits for an adult at rest or during light activity. This finding does not suggest respiratory compromise and does not preclude advancement in rehabilitation.

D. New onset of chest pain 8/10 during ambulation: The sudden development of severe chest pain during activity is a warning sign of myocardial ischemia or reinfarction. Progression in rehabilitation should be halted immediately, and the patient requires urgent assessment and intervention before any further ambulation is attempted.

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When entering the room of a patient who has a chest tube attached to a water-seal drainage system, the nurse observes the chest tube is lying on the floor. Which of the following actions should the nurse take first?

Nursing Test Bank

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Correct Answer is ["A","B","C","D"]

Explanation

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Correct Answer is D

Explanation

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