A nurse in a pediatric emergency department is planning care for an adolescent
Nurses' Notes
2245:
Adolescent arrived via stretcher by Emergency Medical Transport (EMT) following a motor-vehicle crash.
EMT personnel report:
Client was found conscious at the scene inside of the vehicle with airbag deployed, wearing a seat belt.
Vital signs: heart rate: 94/min, respiratory rate 20/min, blood pressure 100/60 mm Hg
18-gauge peripheral IV inserted in left antecubital.
Guardians contacted and report the child has no medical conditions.
2300:
Adolescent reports sharp pain in chest. Rates pain as 6 on a scale of 0 to 10. Respirations fast and shallow. Diminished breath sounds in left lung. S1 and S2 regular and rapid

Based on the information in the adolescent's medical record, which of the following actions should the nurse plan to take?
Select all that apply.
a. Administer a levalbuterol metered dose inhaler.
b. Obtain consent for a pericardiocentesis
c. Prepare for chest tube insertion.
d. Place the adolescent in supine position
e. Apply supplemental oxygen.

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