# A trauma patient who sustained blunt chest injury becomes acutely diaphoretic and hypotensive. The right hemithorax is hyperresonant to percussion, breath sounds are absent on the right, and the trachea is deviated to the left. SpO2 has fallen from 96 to 80 percent on 4 L nasal cannula. Which nursing actions are appropriate before the provider arrives at the bedside? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372844&lang=en  
> language: en  
> subject: Physiological Adaptation  
> category: PA

## Question

A trauma patient who sustained blunt chest injury becomes acutely diaphoretic and hypotensive. The right hemithorax is hyperresonant to percussion, breath sounds are absent on the right, and the trachea is deviated to the left. SpO2 has fallen from 96 to 80 percent on 4 L nasal cannula. Which nursing actions are appropriate before the provider arrives at the bedside? Select all that apply.

1

Rapidly transport the patient to the CT scanner to confirm the diagnosis of tension pneumothorax before initiating any immediate intervention.

2

Call the provider STAT and request an immediate bedside intervention; tension pneumothorax is a clinical diagnosis and should not wait for chest x-ray.

3

Prepare a 14-gauge angiocatheter and a chest-tube insertion tray for definitive management after needle decompression.

4

Apply 100 percent oxygen via non-rebreather mask while preparing for emergent needle decompression at the second intercostal space, midclavicular line.

5

Place the patient on continuous cardiac and SpO2 monitoring and ensure two functional large-bore IV lines for fluid resuscitation.

## Explanation

Tension pneumothorax is a clinical diagnosis — the combination of absent breath sounds, hyperresonance, contralateral tracheal deviation, and obstructive shock physiology mandates immediate decompression rather than imaging. Definitive management is needle decompression (2nd ICS midclavicular line, or 4th–5th ICS anterior axillary line in adults) followed by chest tube. Transporting to CT is contraindicated because it delays life-saving intervention.

## In-depth explanation

Tension PTX kills by compressing the great vessels and obstructing venous return — every minute of imaging is a minute closer to PEA arrest. The nurse provides 100 percent O2, alerts the provider STAT, sets up needle decompression and chest-tube trays, ensures monitoring and IV access, and never sends the patient to CT to confirm a clinical emergency.

## Clinical scenario

**Blunt chest trauma patient** abruptly becomes **diaphoretic and hypotensive**. The right hemithorax is **hyperresonant**, breath sounds are absent on the right, and the trachea is **deviated to the left**. SpO2 falls from 96 to 80 percent on 4 L nasal cannula. The clinical picture is **tension pneumothorax**.

## Key concepts

- **Tension pneumothorax** — One-way valve air leak into the pleural space producing ipsilateral hyperresonance, contralateral tracheal deviation, and obstructive shock.
- **Needle decompression** — Insertion of a 14-gauge angiocatheter at the 2nd ICS midclavicular line (or 4th–5th ICS anterior axillary line in adults) to convert tension to simple pneumothorax.
- **Tracheal deviation** — Trachea shifted away from the affected side under tension pneumothorax physiology; a late and ominous sign.

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