Respiratory Question #25

Question

The nurse contacts the healthcare provider about a client’s assessment following chest tube removal and reports signs of tension pneumothorax such as tracheal deviation away from the affected side, agitation, and neck vein distention. Which action will the nurse perform while waiting for re-insertion of the chest tube?

Answers

  1. Release the dressing covering the open chest wound.
    • Rationale:
  2. Administer oxygen at 80% FiO2.
    • Rationale:
  3. Place the client in trendelenburg position.
    • Rationale:
  4. Perform arterial blood gas.
    • Rationale:

Overview

Explanation

The nurse should immediately release the covering where the previous chest tube was placed. This may become a medical emergency and will have the chest tube reinserted because of build-up of intrathoracic pressure in the pleural space and air cannot escape. One cause could be occlusion of the chest wound (where previous chest tube was inserted). Perhaps the previous chest tube was removed too soon. None of the other selections are appropriate actions.

Learning Outcomes

Test Taking Tip

Video Rationale