NCLEX Practice Test

If a client's chest tube drainage system falls and the tube becomes dislodged, what is the nurse's priority action?

1. Activate the hospital emergency response system

2. Apply supplemental oxygen and transport to the new unit

3. Check the client's respiratory pattern and effort, and oxygen saturation

4. Firmly cover the insertion site with the palm of a clean, gloved hand

The correct answer is: Firmly cover the insertion site with the palm of a clean, gloved hand

The priority action in this scenario is to firmly cover the insertion site with the palm of a clean, gloved hand. This action is crucial because it helps to prevent air from entering the pleural space, which could lead to a tension pneumothorax—a life-threatening condition. By covering the site, the nurse helps to maintain the integrity of the pleural cavity until a more permanent solution can be implemented, such as re-establishing the chest tube or seeking further medical intervention. In this critical situation, addressing the immediate risk of air entering the pleural space takes precedence over other actions. Although checking the client's respiratory pattern, oxygen saturation, and activating emergency response could be important subsequent steps, they follow the immediate need to protect the insertion site. Ensuring the safety and stabilization of the airway and breathing by preventing additional air entry is paramount.