Question

The nurse is caring for a patient who has a chest drainage system. Which assessment findings may indicate that the patient is at risk for developing a tension pneumothorax?

1) Decreased breath sounds on the affected side
2) Tracheal deviation away from the affected side
3) Chest pain and shortness of breath
4) Subcutaneous emphysema

Answer 1

Assessment findings indicating a risk for tension pneumothorax include decreased breath sounds, tracheal deviation, chest pain with shortness of breath, and subcutaneous emphysema, which require immediate attention to prevent life-threatening complications.

Step-by-step explanation:

Assessment findings that may indicate a patient with a chest drainage system is at risk for developing a tension pneumothorax include decreased breath sounds on the affected side, tracheal deviation away from the affected side, chest pain and shortness of breath, and subcutaneous emphysema. Tension pneumothorax is a life-threatening condition that occurs when air collects in the pleural space, leading to increased intrapleural pressure that compresses the lung and other vital structures, such as the heart and great vessels, and can shift the mediastinum.

This can result in hypoxemia, as the lung on the affected side is unable to properly expand and facilitate gas exchange. It is critical for a nurse to assess for these signs and symptoms and take appropriate action to prevent further complications, such as immediately notifying the healthcare provider and preparing for interventions to decompress the affected pleural space.