Medical Surgical Chest tube #3
The nurse is assisting the health care provider in the removal of a chest tube. How will the nurse instruct the client during the procedure?
- “Breathe in and out while concentrating on a fixed object in the room.”
This answer is not correct because breathing in and out normally during chest tube removal will allow for air to enter the insertion site and the pleural space. This could lead to the development of a pneumothorax as air enters the pleural space through the exposed insertion site during inspiration.
- “Hold your breath and bear down while the tube is being removed to keep air from entering back into the area.”
This answer is correct because the nurse should instruct the client to hold their breath and bear down which is called the Valsalva maneuver during the chest tube removal. This causes an increase in intrathoracic pressure and helps decrease the potential for air to enter the pleural space.
- “Do pursed-lip breathing then short huffing breaths while the tube is being removed to keep air from entering into the area.”
This answer is not correct because the client should be instructed to hold their breath during removal of the chest tube. Any breathing during this procedure will allow air to enter the pleural space leading to a pneumothorax.
- “Hold my hand and close your eyes while the tube is being removed since anxiety will cause you to breathe too quickly.
This answer is not correct because, while methods to decrease anxiety are encouraged, the client should be instructed to completely hold their breath during this procedure.
The focus of this question is the proper client education for a client during chest tube removal. It is essential to teach the client to hold their breath during the procedure to prevent entry of air into the insertion site during removal and until the opening is sealed.
Chest tubes are inserted to drain fluid or air from the pleural space in order to promote full lung reexpansion during respirations. The nurse may be asked to assist the provider with either insertion of removal. During chest tube removal, it is essential that air is prevented from entering the insertion site once the tube is removed. If air is allowed to enter the pleural space, it could result in a tension pneumothorax. The nurse should instruct the client to hold their breath and bear down during removal to prevent this entry of air.
Test Taking Tip
Look at each answer choice carefully. Answer choice # 2 is the only answer choice that includes the client holding their breath. Typically, if one answer choice completely differs from all others, it must be further examined as it is most likely the correct answer.