A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take?
a. Position the patient so that the left chest is dependent.
b. Tape a nonporous dressing on three sides over the chest wound.
c. Cover the sucking chest wound firmly with an occlusive dressing.
d. Keep the head of the patient's bed at no more than 30 degrees elevation.
ANS: B
The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.
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