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Difficulty: HardPhysiological Adaptation

A client with a history of chronic obstructive pulmonary disease (COPD) presents with sudden, severe dyspnea and extreme agitation. Assessment reveals absent breath sounds over the right lung field, jugular venous distention, and a trachea deviated to the left. The client's blood pressure is 78/4278/42 mm Hg, and the heart rate is 136136 bpm. A rapid arterial blood gas (ABG) analysis shows a pH of 7.247.24, PaCO2PaCO_2 of 6868 mm Hg, and HCO3−HCO_3^- of 2626 mEq/L. Which of the following is the priority nursing action?

  1. A
    Administer a rapid isotonic intravenous fluid bolus to treat the underlying hypovolemic shock.
  2. Prepare the client for immediate needle thoracostomy and chest tube placement.Answer
  3. C
    Administer intravenous sodium bicarbonate to correct the severe uncompensated acidosis.
  4. D
    Request a stat portable chest radiograph to confirm the diagnosis prior to treatment.

Answer

Prepare the client for immediate needle thoracostomy and chest tube placement.
The client is exhibiting classic signs of a tension pneumothorax (absent breath sounds, tracheal deviation, jugular venous distention, and obstructive shock). This is a life-threatening emergency requiring immediate decompression of the pleural space via needle thoracostomy, followed by chest tube insertion.

Step-by-Step Solution

1
Analyze the physical assessment findings.
Absent right breath sounds, left tracheal deviation, and jugular venous distention indicate a right-sided tension pneumothorax.
Air trapped in the pleural space increases intrathoracic pressure, collapsing the right lung and shifting the mediastinum to the left.
2
Evaluate the hemodynamic and ABG data.
Hypotension and tachycardia signify obstructive shock. The ABG shows uncompensated respiratory acidosis (low pH, high PaCO2PaCO_2, normal HCO3−HCO_3^-).
The mediastinal shift obstructs venous return to the heart, causing shock, and the collapsed lung prevents adequate ventilation.
3
Determine the highest priority intervention.
Immediate mechanical decompression of the pleural space is required.
Delaying treatment for diagnostics or administering fluids and medications fails to resolve the mechanical obstruction that is causing the life-threatening shock and acidosis.

Key Concept

Tension pneumothorax causes obstructive shock and respiratory acidosis, requiring immediate clinical diagnosis and emergency decompression rather than delayed diagnostic testing or pharmacological management.
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Physiological Adaptation

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