NCLEX RN Practice Question # 394

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Pneumothorax

Pneumothorax. Air in the pleural space causes the lungs to collapse around the hilus and may push the mediastinal contents (heart and great vessels) toward the other lung.

  1. Description
  2. Accumulation of atmospheric air in the pleural space, which results in a rise in intrathoracic pressure and reduced vital capacity
  3. The loss of negative intrapleural pressure results in collapse of the lung.
  4. A spontaneous pneumothorax occurs with the rupture of a pulmonary bleb.
  5. An open pneumothorax occurs when an opening through the chest wall allows the entrance of positive atmospheric air pressure into the pleural space.
  6. A tension pneumothorax occurs from a blunt chest injury or from mechanical ventilation with PEEP when a buildup of positive pressure occurs in the pleural space.
  7. Diagnosis of pneumothorax is made by chest x-ray.
  8. Assessment

Absent breath sounds on affected side

Cyanosis

Decreased chest expansion unilaterally

Dyspnea

Hypotension

Sharp chest pain

Subcutaneous emphysema as evidenced by crepitus on

palpation

Sucking sound with open chest wound

Tachycardia

Tachypnea

Tracheal deviation to the unaffected side with tension

pneumothorax

Interventions

  • Apply a dressing over an open chest wound.
  • Administer oxygen as prescribed.
  • Place the client in a Fowler’s position.
  • Prepare for chest tube placement, which will remain in place until the lung has expanded
  • fully.
  • Monitor the chest tube drainage system.
  • Monitor for subcutaneous emphysema.
  • See Chapter 21 for information on caring for a client with chest tubes.

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