A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic
What action by the nurse is the priority?
a.
Administer oxygen and reassess.
b.
Auscultate the client's lung sounds.
c.
Facilitate a portable chest x-ray.
d.
Prepare to assist with intubation.
ANS: D
This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.
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