Question

a nurse is caring for a client who has a chest tube in place that is attached to a closed chest drainage system. which of the following actions should the nurse take if the chest tube becomes dislodged from the closed chest drainage system? instruct the client to inhale deeply. submerge the end of the chest tube in 2.5 cm (1 in) of sterile water. gently milk the chest tube in a proximal - to - distal direction. tape sterile gauze around the open end of the chest tube.

Explanation:

When a chest - tube becomes dislodged from the closed - chest drainage system, submerging the end of the chest tube in 2.5 cm (1 in) of sterile water creates a water seal, preventing air from entering the pleural space and maintaining negative pressure. Instructing the client to inhale deeply is not the appropriate immediate action. Milking the chest tube is for maintaining patency, not for a dislodged tube situation. Taping sterile gauze around the open end may not effectively prevent air entry.

Answer:

Submerge the end of the chest tube in 2.5 cm (1 in) of sterile water.