The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation. The client's oxygen saturation has dropped from 94% to 86%. What is the priority action by the nurse?
a. Encourage the client to take deep, con-trolled breaths.
b. Document findings and continue to moni-tor the client.
c. Notify the health care provider and pre-pare for intubation.
d. Stabilize the chest wall with rib binders.
C
This client has a flail chest characterized by paradoxical chest wall motion. With the oxygen sa-turation dropping, the client is at high risk for respiratory failure and needs to be intubated. Deep-breathing exercises are not enough at this point. Rib binders are not used anymore because they limit chest wall expansion and were used only for simple rib fractures.
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