Question

The nurse in the emergency room is caring for a client with multiple rib fractures and a pulmonary contusion. Assessment reveals a respiratory rate of 38, a heart rate of 136, and restlessness. Which associated assessment finding would require immediate intervention?

Occasional small amounts of hemoptysis
Midline trachea with wheezing on auscultation
Subcutaneous air and absent breath sounds
Pain when breathing deeply, with rales in the upper lobes

Answer 1

The associated assessment finding that would require immediate intervention is subcutaneous air and absent breath sounds. Subcutaneous air indicates a condition called pneumothorax, which occurs when air leaks into the space between the chest wall and lungs. Immediate intervention would be required to relieve the pneumothorax and restore normal respiratory function.

Step-by-step explanation:

The associated assessment finding that would require immediate intervention is subcutaneous air and absent breath sounds.

Subcutaneous air indicates a condition called pneumothorax, which occurs when air leaks into the space between the chest wall and lungs. This can cause lung collapse and significant respiratory distress. Absent breath sounds suggest that there is little to no air movement in the affected lung.

Immediate intervention would be required to relieve the pneumothorax and restore normal respiratory function. This may involve inserting a chest tube to remove air from the pleural space and re-expanding the lung.