NCLEX-PN
Nclex Exam Cram Practice Questions Questions
Extract:
Question 1 of 5
A client with a closed chest tube drainage system accidentally disconnects the chest tube while being turned by the nurse. What should the nurse do first?
Correct Answer: A
Rationale: When a chest tube becomes disconnected, the priority action is to immediately reattach it to the drainage system or submerge the end in a bottle of sterile water or saline solution to reestablish a water seal. This helps prevent air from entering the pleural space and causing complications. Calling the health care provider is important but not the first action in this emergency. Instructing the client to inhale and hold his breath should be avoided as it can introduce atmospheric air into the pleural space, leading to potential issues. Clamping the chest tube is generally contraindicated, especially in cases of residual air leak or pneumothorax, as it may result in a tension pneumothorax by preventing air from escaping.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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