A client presents to the emergency department with a stab wound to the chest. The nurse assesses tachycardia, tachypnea, and a sucking sound coming from the wound. Which of the following actions is priority?

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11ecbb05_ca76_da5c_b433_3392a9d90894_MD0009_00 In a traumatic, or "open," pneumothorax, air rushes in through the wound with each inspiration, creating a sucking sound, and fills the pleural space. The lungs cannot expand, so the client develops respiratory distress and air hunger. Tachycardia and hypotension result from impaired venous return, as the heart and great vessels shift with each breath. A tension pneumothorax may also develop if air cannot escape the pleural space. The priority action in this medical emergency is to apply a sterile occlusive dressing (eg, petroleum gauze) taped on three sides, preventing inward air flow while allowing air to escape the pleural space. (Option A) This client's tachycardia and hypotension are likely related to pneumothorax and should improve once the pneumothorax is resolved; administering fluids alone would not help if the pneumothorax continues to worsen. Fluids are given to treat blood loss hypotension, but this should not be the first step in this case. (Option B) Supplemental oxygen should be applied as needed after covering the wound. If possible, correcting the underlying cause is always a priority over treating manifestations. (Option C) After covering the wound, chest tube placement is usually performed to evacuate air and blood from the pleural cavity. The client may need more than one chest tube to evacuate both air (placed higher) and fluid or blood (placed lower). Educational objective: A sucking chest wound indicates a traumatic, or "open," pneumothorax and is a medical emergency. Respiratory distress results from inability to expand the lung. The priority action is to apply a sterile occlusive dressing (eg, petroleum gauze) taped on three sides.

A Client Presents to the Emergency Department with a Stab