Author Question: During assessment of a client, the chest tube becomes dislodged. The nurse should first: A. Call ... (Read 52 times)

RRMR · **on:** Jul 23, 2018

During assessment of a client, the chest tube becomes dislodged. The nurse should first:

A. Call the physician
B. Check for a mediastinal shift
C. Attempt to gently reinsert the tube
D. Apply pressure over the insertion site

Question 2

For the adult client with a pleural chest tube, the expected amount of drainage is:

A. 100 to 3000 ml during the first 3 hours
B. 10 to 50 ml during the first 2 hours
C. 200 ml during the first 24 hours
D. 400 to 500 ml during the first 24 hours

cat123 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

D
D. If chest tube becomes dislodged, immediately apply pressure over chest tube insertion site.
A. Have assistant apply gauze dressing and tape three sides. Notify physician.
B. If there is no chest drainage, observe for mediastinal shift or respiratory distress (medical emergency).
C. If chest tube becomes dislodged, immediately apply pressure over chest tube insertion site. Have assistant apply gauze dressing and tape three sides.

Answer to Question 2

A
A and B. In the adult, between 100 and 3000 ml of fluid may drain from a pleural tube during the first 3 hours after insertion.
C and D. The 24-hour rate is 500 to 1000 ml/hour.