The nurse is planning care for a patient with obstructive shock as a result of a tension pneumothorax. The patient has a chest tube to water seal and suction
Which of the following would the nurse include in the plan of care for this patient? 1. monitor urine output
2. prepare to intubate
3. maintain chest tube seal and record output
4. palpate peripheral pulses
3
Rationale: On insertion of a chest tube for the patient with a tension pneumothorax, the lung should reinflate, which requires the nurse to assess for chest symmetry, monitor oxygen saturation, maintain chest tube seal and record output, monitor blood pressure, administer oxygen, and auscultate lung sounds. Monitoring urine output and palpating peripheral pulses is not indicated for this patient. There is not enough information to suggest the patient needs to be intubated.
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