49. Dislodged chest tube.胸管脱落病人

The nurse is called to a client’s room to assist the client who has a chest tube. The client states that it feels as if the tube has pulled out of the chest. The nurse assesses the client and finds that the tube has dislodged and is lying on the floor. What action would the nurse take next? 1. Ask for a pair of sterile gloves. 2. Contact the charge nurse for help. 3. Cover the insertion site with a sterile dressing. 4. Submerge the dislodged tube into sterile water. Answer: 3 Test-Taking Strategy: Note the strategic word,next. Recognize cues in the question, and analyze the cues for their significance to identify the action that needs to be taken. When providing care to a client, particularly in emergency situations, keep in mind that all of the resources needed to provide client care will be readily available at the client’s bedside. Most students would eliminate option 4 first, knowing that this action is not necessary in this scenario. From the remaining options, you may think, “I don’t have sterile gloves or a sterile dressing with me, so let me call for help first st.” Remember, you have everything you need wherever and whenever you need it!