A nurse is assessing a patient following a gunshot wound to the chest.
For which of the following findings should the nurse monitor to detect a pneumothorax?

Choice A rationale

Occasional expiratory wheezes can be a sign of bronchoconstriction but do not necessarily indicate a need for immediate suctioning. Suctioning is primarily indicated for the presence of secretions that obstruct the airway, not for bronchospasm, which is typically treated with bronchodilators.

Choice B rationale

Suctioning is a procedure based on patient assessment findings, not a predetermined schedule. Performing the procedure on a timed basis, without clinical indication, can cause trauma to the tracheal and bronchial mucosa, increasing the risk of infection and bleeding.

Choice C rationale

A pulse oximeter reading of 93% is within the acceptable range for many patients and does not, by itself, indicate the need for suctioning. The need for suctioning is based on the presence of secretions, not solely on oxygen saturation levels, unless there is a significant drop in SpO$_2$.

Choice D rationale

A respiratory rate of 32 breaths/min indicates increased respiratory effort and distress. This tachypnea may be a sign of airway obstruction from secretions, which the patient is trying to clear. The nurse should perform an assessment, including auscultation, and consider suctioning. *.

Choice A rationale

In the initial stages of hypoxemia, the body's compensatory response involves activating the sympathetic nervous system to increase oxygen delivery. This sympathetic surge leads to vasoconstriction and an increase in heart rate, resulting in elevated blood pressure. This is a temporary mechanism to improve tissue perfusion and is a key early sign before the decompensation phase begins. Normal systolic blood pressure is less than 120 mmHg and diastolic is less than 80 mmHg.

Choice B rationale

Pale skin, or pallor, is an early and observable manifestation of hypoxemia. This is a result of peripheral vasoconstriction, a compensatory mechanism triggered by the sympathetic nervous system to shunt blood from the periphery to vital organs like the heart and brain. This reduction in peripheral blood flow leads to the skin appearing pale, particularly in the extremities and mucous membranes.

Choice C rationale

Confusion is an early and significant neurological sign of cerebral hypoxemia. The brain is highly sensitive to changes in oxygen levels. As oxygen saturation drops, cerebral function is impaired, leading to altered mental status, confusion, restlessness, and anxiety. This is one of the most reliable indicators of impending respiratory failure.

Choice D rationale

Hypotension is typically a late sign of hypoxemia, indicating a state of decompensation and impending circulatory collapse. As the body's compensatory mechanisms fail to maintain adequate cardiac output and oxygen delivery, the patient's blood pressure will drop. This is a critical and ominous finding, suggesting that the patient is in a state of shock and requires immediate intervention