A patient with a chest tube has tubing that becomes disconnected from the drainage system. What should the nurse do first?
Correct answer: A. Place the end of the tube in sterile water
- A. Place the end of the tube in sterile water
- B. Clamp the chest tube close to the patient
- C. Remove the chest tube and apply a dry dressing
- D. Reconnect the tubing after washing it with tap water
Explanation
Placing the disconnected tube end in sterile water creates a temporary water seal and helps prevent air from entering the pleural space. Routine clamping can cause a tension pneumothorax. The system should then be replaced or reconnected according to local policy.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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