Final answer:
The first action a nurse should perform when assisting with a patient who has a spontaneous pneumothorax is to prepare for chest tube insertion, as it is crucial to re-expand the collapsed lung and ensure proper breathing.
Step-by-step explanation:
The nurse should perform the most critical action first when dealing with a patient who has developed a spontaneous pneumothorax. In this scenario, the primary concern is to ensure the patient can breathe adequately. Spontaneous pneumothorax can lead to decreased oxygenation and difficulty breathing. Therefore, the first action a nurse should take is to prepare for chest tube insertion (D). This procedure is vital to re-expand the collapsed lung and restore normal respiratory function.
While assessing the client's pain (A) and obtaining a large-bore IV needle for decompression (B) are important steps, they follow in priority after addressing the immediate threat to the client's breathing. Administering lorazepam (C) may be contemplated for anxiety or agitation, but this is not the first action to take in an emergency situation like a spontaneous pneumothorax.
The clinical team, including the surgeon, nurse, and anesthesia professional, will review aloud the key concerns for the recovery and care of the patient. This collaborative approach ensures all aspects of care are considered and the patient's safety is prioritized. While techniques like the Heimlich maneuver are used to help force an aspirated object out of the respiratory tract, they are related to a different emergency and are not the procedure of choice for treating a pneumothorax.