Question

A client who is admitted to the emergency room following a motorcycle accident is having difficulty breathing. While assessing the clients chest and lungs, the nurse notes that there are no breath sounds over the left fields. Which actions should the nurse implement? (Select all that apply)

A- Apply a high-flow oxygen by face mask
B- Elevate the head of the bed 45 degrees
C- Place client in Trendelenburg position
D- Withhold narcotic pain medication
E- Obtain a chest tube

Answer 1

When a client is having difficulty breathing with no breath sounds over the left lung fields after a motorcycle accident, the nurse should apply high-flow oxygen by face mask, elevate the head of the bed 45 degrees, and obtain a chest tube.

Step-by-step explanation:

When a client who is admitted to the emergency room following a motorcycle accident is having difficulty breathing and there are no breath sounds over the left lung fields, the nurse should implement the following actions:

1. Apply a high-flow oxygen by face mask: Providing supplemental oxygen can help improve oxygenation and alleviate breathing difficulties.
2. Elevate the head of the bed 45 degrees: This position helps optimize lung expansion and improve respiratory function.
3. Obtain a chest tube: Absence of breath sounds may indicate a pneumothorax, which requires a chest tube insertion to remove air from the pleural space and reestablish lung expansion.

The other options are not appropriate in this situation. Placing the client in Trendelenburg position may worsen the breathing difficulty, withholding narcotic pain medication may compromise pain management, and ordering a chest tube is the appropriate action rather than obtaining a sputum sample.