The nurse is assessing a patient who was in an automobile crash. Which finding would most likely indicate to the nurse that the patient may have developed a tension pneumothorax?

Tracheal deviation towards the unaffected side

Wheezing breath sounds over the affected area

Rales breath sounds over the affected area

Tracheal deviation towards the affected side

Answer and Explanation

The Correct Answer is A

A. Tracheal deviation towards the unaffected side: In tension pneumothorax, air accumulates in the pleural space under pressure, compressing the lung and shifting mediastinal structures. The trachea deviates away from the affected side (toward the unaffected side), which is a hallmark sign, along with hypotension, distended neck veins, and severe respiratory distress.

B. Wheezing breath sounds over the affected area: Wheezing indicates airway narrowing, commonly seen in asthma or bronchospasm. It does not reflect the pathophysiology of tension pneumothorax, which involves lung collapse and mediastinal shift rather than bronchial constriction.

C. Rales breath sounds over the affected area: Rales are fine crackles produced by fluid in the alveoli, typically seen in pulmonary edema or pneumonia. They are not characteristic of a tension pneumothorax, where breath sounds are diminished or absent over the affected side.

D. Tracheal deviation towards the affected side: Tracheal deviation toward the affected side occurs in lung collapse from atelectasis, not tension pneumothorax. In tension pneumothorax, the pressure pushes the mediastinum away from the affected side.

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Correct Answer is B

Explanation

A. Assess how the chest tube became disconnected from the drainage system: Determining how the disconnection occurred is important for quality improvement and preventing recurrence, but it is not the immediate priority. The first concern is preventing air from entering the pleural space and causing a tension pneumothorax.

B. Place the end of the chest tube into a container of sterile water: Immediately submerging the distal end of the chest tube in sterile water re-establishes a temporary water seal. This prevents air from being drawn back into the pleural cavity during inspiration, reducing the risk of lung collapse or tension pneumothorax.

C. Apply an occlusive dressing to the chest tube insertion site: An occlusive dressing would be appropriate if the tube were completely dislodged from the patient’s chest. In this situation, the tube is disconnected from the drainage system, not from the insertion site, so sealing the site does not address the current problem.

D. Auscultate the lung sounds: Assessing breath sounds is important after stabilizing the system, but assessment does not take priority over preventing air entry into the pleural space. Immediate corrective action is required before further evaluation.

A. Provide oral care every 12 hours B. Monitor ETT cuff pressure C. Insert a nasogastric tube D. Administer high doses of sedation E. Maintain head of the bed to at least 30 degrees

Correct Answer is ["B","E"]

Explanation

A. Provide oral care every 12 hours: Oral care is an essential component of VAP prevention; however, every 12 hours is insufficient for mechanically ventilated patients. Evidence-based bundles recommend more frequent oral care, often every 2–4 hours, typically with chlorhexidine to reduce oropharyngeal colonization. This frequency does not meet best-practice standards.

B. Monitor ETT cuff pressure: Maintaining appropriate endotracheal tube cuff pressure (usually 20–30 cm H₂O) helps prevent microaspiration of contaminated oral and gastric secretions into the lower airway. Inadequate cuff pressure increases the risk of pathogen entry into the lungs, making regular monitoring a critical VAP prevention strategy.

C. Insert a nasogastric tube: Insertion of a nasogastric tube does not prevent VAP and may increase the risk of aspiration if not managed properly. Gastric distention and reflux can contribute to aspiration of gastric contents, thereby increasing pneumonia risk rather than reducing it.

D. Administer high doses of sedation: High sedation levels suppress cough reflexes, impair early mobilization, and prolong mechanical ventilation duration, all of which increase VAP risk. Current evidence supports daily sedation interruption and light sedation strategies rather than deep sedation.

E. Maintain head of the bed to at least 30 degrees: Elevating the head of the bed between 30–45 degrees reduces the risk of aspiration of gastric and oral secretions. This positioning decreases the likelihood of bacteria entering the lower respiratory tract and is a cornerstone of ventilator bundle protocols.

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The nurse is assessing a patient who was in an automobile crash. Which finding would most likely indicate to the nurse that the patient may have developed a tension pneumothorax?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with a chest tube that is connected to a water seal drainage system. The nurse observes the chest tube is disconnected from the chest tube drainage system. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

Correct Answer is ["B","E"]

Explanation

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