NCLEX-RNPhysiological AdaptationEasy
A client arrives in the emergency department after a stab wound to the right chest. The nurse notes absent breath sounds on the right, tracheal deviation to the left, jugular venous distention, and a blood pressure of 78/50 mm Hg. Which intervention should the nurse anticipate as the priority?
- AAdminister a 500 mL bolus of normal saline
- BPrepare for immediate needle decompression of the chest
- CApply a three-sided occlusive dressing to the wound
- DObtain a portable chest x-ray to confirm the diagnosis
Show answer & explanationAnswer & explanation
Correct answer: B. Prepare for immediate needle decompression of the chest
Tracheal deviation, absent breath sounds, JVD, and hypotension indicate a tension pneumothorax, a life-threatening emergency caused by air trapped in the pleural space compressing the heart and great vessels. Needle decompression must be performed immediately to relieve pressure before any diagnostic imaging or fluid resuscitation.
Why the other options are wrong
- A. Fluids will not correct the underlying obstructive shock caused by mediastinal shift.
- C. An occlusive dressing is used for an open chest wound, not to relieve tension pneumothorax.
- D. Imaging delays life-saving treatment in an unstable client with classic tension pneumothorax signs.
Tension Pneumothorax
A progressive accumulation of air in the pleural space that shifts the mediastinum and compresses the heart and great vessels, causing obstructive shock.
- Signs: absent breath sounds, tracheal deviation away from affected side, JVD, hypotension
- Treatment: emergency needle decompression followed by chest tube insertion
- Untreated, it rapidly progresses to cardiac arrest
Memory trick: Trachea Tips Away, Treat right away with a needle