Safe, Effective Care Environment
63. While a client is getting out of bed, the chest tube catches on the night stand and is pulled out. What should a nurse do first?
Safe, Effective Care Environment
63. While a client is getting out of bed, the chest tube catches on the night stand and is pulled out. What should a nurse do first?
. Cover the opening with sterile gauze.
. Hold client's gown over opening.
. Put the client back to bed.
. Call the MD for help.
Test-Taking Tip
Priority: Do something to reduce immediate risk to the client—a sucking hole. Consider the two options that include "cover" and choose the one with the most available resource.
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
Safe, Effective Care Environment
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Answer 1 is incorrect because, although plausible, gauze is not occlusive and may not be readily available. Answer 2 is correct because the priority is to prevent air from entering the chest cavity with the most occlusive method. (Gloves might be available, but time is critical.) Answer 3 is incorrect because it would take too much time to reposition the client in bed. Cover the opening immediately, then put the client to bed. Answer 4 is incorrect because the best answer requires action by the nurse, not the physician.