Question

Which immediate action does the nurse take when discovering that a patient's chest tube is disconnected from the chest drainage unit (CDU)?

A. Apply a clamp to the distal end of the chest tube.
B. Place the patient in a supine position.
C. Wrap a petroleum (airtight) gauze over the end of the chest tube.
D. Correct Immerse the distal end of the chest tube in sterile water.

Answer 1

The immediate action a nurse should take when a patient's chest tube is disconnected from the CDU is to immerse the distal end of the chest tube in sterile water to prevent air from entering the pleural space.

Step-by-step explanation:

When a nurse discovers that a patient's chest tube is disconnected from the chest drainage unit (CDU), the immediate action to take is to immerse the distal end of the chest tube in sterile water. This action creates a water seal, preventing air from entering the pleural space, which could lead to a pneumothorax (collapsed lung). It is critical to maintain the vacuum needed for lung re-expansion by keeping the end of the tube submerged in water until the system can be safely and effectively reconnected.

Actions such as clamping the tube might be performed but typically after immediate re-establishment of the water seal. Furthermore, placing a patient in a supine position or wrapping the end of the tube with petroleum gauze are not the initial steps and may not prevent air from entering the pleural space.