58) A nurse is assessing the provider in caring for a client who has developed a tensionpneumothorax. Which actions should be performed first?(a) Assess the client’s pain(b) Large-bone needle thoracostomy(c) Administer lorazepam(d) Prepare for chest tube insertion.
Question
- A nurse is assessing the provider in caring for a client who has developed a tensionpneumothorax. Which actions should be performed first?(a) Assess the client’s pain(b) Large-bone needle thoracostomy(c) Administer lorazepam(d) Prepare for chest tube insertion.
Solution
In a situation where a client has developed a tension pneumothorax, the priority should be to stabilize the patient's condition. Here are the steps in order:
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Assess the client’s pain: This is important but not the first step in this emergency situation. Pain assessment will help in managing the patient's comfort later on.
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Large-bone needle thoracostomy: This should be the first action. A tension pneumothorax is a life-threatening condition that requires immediate intervention to decompress the chest. This is typically done by a procedure called needle thoracostomy, which involves inserting a needle into the chest wall.
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Administer lorazepam: This is not the first step. Lorazepam is a sedative and may be used to help the patient relax, but it is not the primary treatment for tension pneumothorax.
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Prepare for chest tube insertion: After the initial emergency decompression with a needle thoracostomy, the next step is to insert a chest tube. This allows for continued drainage of air from the chest cavity to prevent the pneumothorax from recurring.
So, the correct order of actions should be: Large-bone needle thoracostomy, Prepare for chest tube insertion, Assess the client’s pain, and then Administer lorazepam.
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