Practice Quiz

NCLEX-RN

Category - Reduction of Risk

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A client’s chest tube is pulled out of his chest. Which of the following is the most appropriate action of the nurse?
  1. Instruct the client to take a deep breath, exhale, and bear down.
  2. Clamp the chest tube and notify the physician.
  3. Replace the chest tube system.
  4. Pinch the skin opening together and apply a sterile dressing over the site.
Explanation
Answer - D - If the chest tube is accidentally pulled out of the client’s chest, the most appropriate action is to pinch the skin opening and apply an occlusive sterile dressing over the site. The physician should be promptly notified. Option A is instructed when the chest tube is removed.
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