Home » NCLEX » NCLEX-RN » When she is ambulating. The first action the nurse should take is to:
A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:
A. Instruct the client to cough deeply to re-expand her lung
B. Put on sterile gloves and replace the tube
C. Apply a petrolatum dressing over the site
D. Auscultate the lung to determine if she needs the tube replaced
Correct Answer: C
Explanation/Reference:
Explanation:
(A) This action is inappropriate. Coughing will not re-expand the lung and could result in further harm. (B) This action is a medical procedure, not a nursing procedure. (C) An occlusive dressing will prevent further air leak until the physician institutes further treatment. (D) The decision to reinsert the tube is a medical decision, not a nursing one.
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