Chest Injuries

A 45-year-old construction worker is brought to the emergency department after falling from scaffolding and landing on his left side. He reports severe left-sided chest pain and difficulty breathing. What is the nurse's immediate priority action?

Assessment reveals decreased breath sounds on the left side, tracheal deviation to the right, and jugular vein distention. His vital signs are: BP 90/60 mmHg, HR 120 bpm, RR 28/min, O2 sat 88% on room air.

1 Administer high-flow oxygen via non-rebreather mask
2 Prepare for immediate needle decompression or chest tube insertion ✓ 정답
3 Obtain a chest X-ray to confirm the diagnosis
4 Insert two large-bore IV lines for fluid resuscitation

해설

Immediate needle decompression or chest tube insertion is priority for tension pneumothorax with signs like tracheal deviation and hypotension. Delaying for diagnostics can lead to cardiac arrest.

같은 주제 다음 문제A 35-year-old male patient arrives at the emergency department following a high-speed moto…이 문제가 수록된 문제집[개념+기출] 엔클렉스(NCLEX), 이거 하나면 됩니다69,000원

Clinical Presentation and Pathophysiology
This patient’s presentation is a classic picture of a tension pneumothorax. The mechanism of injury—a fall with blunt trauma to the left chest—can cause a rib fracture or parenchymal lung injury, creating a one-way valve effect. Air enters the pleural space during inspiration but cannot exit during expiration. As intrapleural pressure rises, the affected lung collapses completely. The accumulating pressure then pushes the mediastinum toward the opposite side. This shift explains the assessment findings: tracheal deviation to the right (away from the affected left side), distended neck veins from impaired venous return, and absent breath sounds on the left. The vital signs—BP 90/60 mmHg, HR 120 bpm, RR 28/min, and O2 sat 88%—reflect obstructive shock and severe hypoxemia. The mediastinal shift kinks the great vessels, reducing cardiac preload and cardiac output, which is a life-threatening emergency ^[1].

Priority Action Analysis
In a tension pneumothorax, the immediate threat is the trapped air under pressure causing cardiovascular collapse. The definitive emergency treatment is rapid decompression of the pleural space to relieve the pressure on the heart and great vessels. The cited protocol explicitly states that for unstable patients with life-threatening respiratory distress and hemodynamic instability, the priority is emergency decompression ^[1]. While the other options are components of care, they do not address the root cause of the obstructive shock.

* Option 1 (Administer high-flow oxygen): Oxygenation is critical, but it will not resolve the mechanical compression of the heart and mediastinal shift. The protocol lists supplemental oxygen as a supportive measure, but decompression is the priority for an unstable patient ^[1].
* Option 3 (Obtain a chest X-ray): A tension pneumothorax is a clinical diagnosis. Waiting for radiographic confirmation in a patient with tracheal deviation and hypotension delays a life-saving procedure. The protocol emphasizes rapid diagnosis based on clinical signs, not imaging, for unstable patients ^[1].
* Option 4 (Insert two large-bore IV lines): Fluid resuscitation is a supportive measure for hypotension. However, in obstructive shock from a tension pneumothorax, the primary problem is not hypovolemia but impaired venous return due to increased intrathoracic pressure. Giving fluids without first relieving the obstruction will be ineffective and delays definitive care.

Therefore, the nurse’s immediate priority is to prepare for needle decompression or assist with chest tube insertion. This directly converts the tension pneumothorax to a simple pneumothorax, relieving the mediastinal shift and restoring cardiac output. The protocol confirms that emergency decompression is the required action for unstable patients before urgent transfer for definitive management ^[1].

References (research sources)

[1]
International Pain and Spine Intervention Society Emergency Protocols: Pneumothorax.Research articleWasserman RA, Meral RM, Joshi M. (2026) · DOI: 10.1016/j.inpm.2026.100779

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A 45-year-old construction worker is brought to the emergency department after falling from scaffolding and landing on his left side. He reports severe left-sided chest pain and difficulty breathing. What is the nurse's immediate priority action?

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