The nurse is caring for a client with tension pneumothorax. Which nursing assessment would alert the nurse to the development of a mediastinal shift in this client?

Shift of rib cage toward affected side

Shift of trachea, esophagus, heart, and great vessels

Fluctuation of the fluid in the water-seal chamber

Sucking sound heard on inspiration and expiration

Answer and Explanation

The Correct Answer is B

A. Shift of rib cage toward affected side: The rib cage does not typically shift in tension pneumothorax. Instead, the thorax on the affected side may appear hyperinflated or fixed in inspiration but does not physically shift toward the affected side.
B. Shift of trachea, esophagus, heart, and great vessels: A tension pneumothorax can cause increased intrathoracic pressure, pushing the mediastinal structures toward the unaffected side. This mediastinal shift is a critical sign and can lead to impaired cardiac output and respiratory collapse.
C. Fluctuation of the fluid in the water-seal chamber: This is an expected finding in a chest tube system and indicates proper function. It does not reflect a mediastinal shift and is not specific to tension pneumothorax.
D. Sucking sound heard on inspiration and expiration: This is more commonly associated with an open pneumothorax, not a tension pneumothorax. Tension pneumothorax involves air trapping without an external opening.

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Correct Answer is C

Explanation

A. "Everything will be fine. Your family is here for you.": This response offers reassurance but does not address or validate the client's specific fears. It may feel dismissive of their emotional distress.
B. "Don't cry: you have the best team of doctors.": Although supportive in intent, this response ignores the client’s emotional expression and can shut down open communication about their fears.
C. "Tell me what concerns you most.": This therapeutic response invites the client to express their feelings and fears openly. It helps build trust and allows the nurse to offer emotional support tailored to the client’s needs.
D. "Would you like something to calm your nerves?": Offering medication may be appropriate later, but it bypasses the opportunity to first explore the client's anxiety through conversation and emotional support.

A. Dyspnea when ambulating from the bathroom B. A noted irregular pulse rate prior to Lanoxin (digoxin) administration C. Pulsus paradoxus on vital sign assessment D. Cyanosis with a pulse oximetry level of 92%

Correct Answer is C

Explanation

A. Dyspnea when ambulating from the bathroom: Mild exertional dyspnea is common in cardiac clients and may not require immediate provider notification unless it worsens or becomes unrelieved with rest.
B. A noted irregular pulse rate prior to Lanoxin (digoxin) administration: An irregular pulse may warrant holding the medication and further assessment, but it is not always an emergency unless associated with hemodynamic instability or bradycardia.
C. Pulsus paradoxus on vital sign assessment: Pulsus paradoxus, a significant drop in systolic blood pressure during inspiration, may indicate cardiac tamponade or severe pericardial effusion. It is a critical finding that requires immediate medical attention.
D. Cyanosis with a pulse oximetry level of 92%: While cyanosis is concerning, a SpO₂ of 92% may be acceptable for some cardiac or pulmonary patients. Further monitoring is needed, but it may not require urgent notification unless oxygen levels drop further.

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The nurse is caring for a client with tension pneumothorax. Which nursing assessment would alert the nurse to the development of a mediastinal shift in this client?

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