The nurse is caring for a client in the emergency department who has an open stab wound to the right chest. Which of the following actions should the nurse implement first?
A)Position the client so that the right chest is dependent.
B)Keep the head of the client's bed at no more than 30 degrees elevation.
C)Tape a nonporous dressing on three sides over the chest wound.
D)Cover the sucking chest wound firmly with an occlusive dressing.

Question

Quizplus · Accepted Answer

The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the client on the right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30-45 degrees to facilitate breathing.

The Nurse Is Caring for a Client in the Emergency