Question

A nurse is caring for a client with a chest tube. He notes that the dressing around the client's tube insertion site is wet and there is some crepitus with mild palpation. Which actions by the nurse are most appropriate in this situation? Select all that apply.

a. Prepare for replacement of the tube
b. Keep the tubing below the level of the insertion site
c. Remove the tube and place an occlusive dressing over the site
d. Notify the provider to evaluate the level of suction
e. Gently milk the tubing to remove clots, if present

Answer 1

The nurse's most appropriate actions in this situation are to prepare for replacement of the tube, keep the tubing below the level of the insertion site, and gently milk the tubing to remove clots, if present.

Step-by-step explanation:

The nurse's most appropriate actions in this situation are:

a. Prepare for replacement of the tube
b. Keep the tubing below the level of the insertion site
e. Gently milk the tubing to remove clots, if present

If the dressing around the chest tube insertion site is wet, it may indicate a leakage or dislodgment of the tube, requiring its replacement. Keeping the tubing below the level of the insertion site helps prevent air or fluid from flowing back into the patient's chest. Gently milking the tubing can help remove clots that may be obstructing the flow.

Actions c and d are not appropriate in this situation. Removing the tube and placing an occlusive dressing would not address the underlying issue, and notifying the provider to evaluate the level of suction may not be necessary unless there are other concerning signs or symptoms.