Question

Immediately following the removal of a chest tube, the nurse would: A. Order a chest \(x\)-ray B. Take the blood pressure C. Cover the insertion site with a Vaseline gauze D. Ask the client to perform the Valsalva maneuver

Short answer

Answer: The most appropriate action for a nurse to take immediately following the removal of a chest tube is to cover the insertion site with a Vaseline gauze. This creates an occlusive dressing that prevents air from entering the pleural space through the puncture site, reducing the risk of complications.

Step-by-step solution

Analyzing each option

The first step is to analyze each option and determine which one is the most appropriate action for the nurse to take immediately after the removal of a chest tube. a) Ordering a chest x-ray is commonly done after a chest tube removal to check the lung for any complications that may have arisen during the procedure. However, this is not the immediate action that should be taken. b) Taking the blood pressure is generally a necessary action to evaluate the client's vital signs. However, this is not the specific action that needs to be taken immediately following chest tube removal. c) Covering the insertion site with a Vaseline gauze is an appropriate action after the removal of a chest tube. This is done to create an occlusive dressing that will prevent air from entering the pleural space through the puncture site. d) Asking the client to perform the Valsalva maneuver is not the appropriate action, as it could increase the risk of pneumothorax due to increased intrathoracic pressure.

Selecting the correct action

Based on the analysis, the correct action to be taken by the nurse immediately after the removal of a chest tube is C. Cover the insertion site with a Vaseline gauze. This will help create an occlusive dressing that prevents air from entering the pleural space through the puncture site, reducing the risk of complications.