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Difficulty: Very hardReduction of Risk Potential

A 32-year-old client is admitted to the emergency department following a high-speed motor vehicle collision. The client sustained blunt trauma to the anterior chest. The nurse's initial assessment reveals a blood pressure of 88/54 mm Hg, heart rate of 134 bpm, and respiratory rate of 32 breaths/min. The client's trachea is deviated to the left, and jugular venous distention (JVD) is present despite the head of the bed being elevated to 45 degrees. An arterial blood gas (ABG) analysis on room air shows pH 7.28, PaCO2 56 mm Hg, HCO3 24 mEq/L, and PaO2 58 mm Hg. Which action should the nurse take FIRST?

  1. Prepare the client for an emergent right-sided needle thoracostomy.Answer
  2. B
    Initiate a rapid intravenous fluid bolus of 1,000 mL of 0.9% sodium chloride.
  3. C
    Lower the head of the bed to a flat, supine position to optimize cerebral perfusion.
  4. D
    Administer intravenous sodium bicarbonate to correct the uncompensated metabolic acidosis.

Answer

The correct action is to prepare the client for an emergent right-sided needle thoracostomy.
The client's presentation of profound hypotension, tachycardia, jugular venous distention, and left-sided tracheal deviation strongly indicates a right-sided tension pneumothorax. This condition traps air in the pleural space, creating massive intrathoracic pressure that compresses the great vessels and heart, leading to obstructive shock and cardiopulmonary collapse. The immediate, life-saving intervention is to relieve this pressure through an emergent needle thoracostomy (decompression) on the affected right side, followed by a chest tube insertion.

Step-by-Step Solution

1
Analyze the clinical assessment findings.
The client presents with severe hypotension, tachycardia, jugular venous distention (JVD), and a trachea deviated to the left.
These are the hallmark signs of a tension pneumothorax. The leftward tracheal deviation specifically isolates the pathology to the right side of the chest.
2
Differentiate the type of shock present.
The client is experiencing obstructive shock, not hypovolemic shock.
Trapped air in the pleural space creates massive intrathoracic pressure, physically compressing the heart and great vessels. This mechanical obstruction prevents venous return (causing JVD) and drastically reduces cardiac output (causing hypotension).
3
Interpret the arterial blood gas (ABG) values.
pH 7.28 (acidosis), PaCO2 56 mm Hg (respiratory acidosis), HCO3 24 mEq/L (normal), and PaO2 58 mm Hg (severe hypoxemia).
This confirms acute, uncompensated respiratory acidosis resulting from the collapsed lung's inability to ventilate and oxygenate.
4
Determine the highest priority nursing intervention.
Preparation for immediate pleural decompression (needle thoracostomy) on the right side.
Relieving the trapped air is the only definitive way to reverse the mechanical obstruction, restore cardiac output, and allow the lung to re-expand. Other interventions like fluids or positioning will not correct the underlying life-threatening pathology.

Key Concept

Tension Pneumothorax and Obstructive Shock Management
Estimated Time:2m 0s
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Topics

Reduction of Risk Potential

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