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    Hesi Rn compass exit B proctored exam

    While transferring a client with a chest tube from the bed to a stretcher, the chest tube becomes disconnected from the water- seal drainage container. The nurse immediately immerses the end of the tube in a container of sterile water. Which action should the nurse implement next?

    Explanation & Rationale

    Rationale: A. Prepare a new water-seal system and reattach the chest tube: After temporarily placing the disconnected tube in sterile water to prevent air entry, the priority is to re-establish a closed drainage system to maintain negative intrathoracic pressure and prevent complications like tension pneumothorax. B. Clamp the chest tube and maintain its distal end in the water: Clamping a chest tube can increase the risk of tension pneumothorax by trapping air inside the pleural cavity. It should only be done momentarily and under specific circumstances. C. Apply pressure to the chest tube site using a petroleum gauze: This is appropriate if the chest tube becomes dislodged from the insertion site, not if it's disconnected from the drainage system. The insertion site remains intact in this case. D. Begin manual ventilation while returning the client to the bed: There is no indication of respiratory distress or collapse requiring manual ventilation. The immediate need is to restore the chest tube drainage system.

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