Question

After undergoing a right lower lobectomy for treatment of lung cancer, a 75-year-old client returns to his room with a chest tube in place. Several hours later, a nurse finds the client out of bed barely able to speak, with the chest tube removed. Which action should the nurse take immediately?

a) Assist the client back to bed and notify the healthcare provider.
b) Reinsert the chest tube immediately without delay.
c) Cover the insertion site with an occlusive dressing, call for assistance, and remain with the client.
d) Check the client's oxygen saturation and administer oxygen if low.

Answer 1

In this situation, the nurse should immediately cover the insertion site with an occlusive dressing, call for assistance, and remain with the client. Checking oxygen saturation and administering oxygen may be necessary, but it is not the most immediate action.

Step-by-step explanation:

In this situation, the nurse should take action (c) - cover the insertion site with an occlusive dressing, call for assistance, and remain with the client. This is the correct action because the client is out of bed and the chest tube has been removed, which can lead to serious complications such as pneumothorax (collapsed lung).

By covering the insertion site with an occlusive dressing, the nurse helps prevent air from entering the chest cavity and potentially collapsing the lung. Calling for assistance is important to ensure that the client can be safely returned to bed and continues to receive appropriate care. Remaining with the client ensures their safety and immediate access to any necessary interventions.

Checking the client's oxygen saturation and administering oxygen if low (option d) may be necessary after the immediate action of covering the insertion site, but it is not the most immediate action to be taken.