MSN Exam for Pneumothorax

EXPLANATION

 

✔Correct answer:

Reduced breath sounds upon auscultation. In cases of chest wall injury where there is suspicion of pneumothorax, reduced or absent breath sounds upon auscultation are a significant indicator. A pneumothorax occurs when there is air in the pleural space, which can cause lung collapse. When a lung or a portion of it collapses, it would not participate in ventilation, leading to an absence or significant reduction in breath sounds when listening with a stethoscope. Nurse Lisa should be keen to perform auscultation on both sides of Karen's chest to compare the breath sounds. If she notices reduced breath sounds on the side of the injury, this is a strong indicator that a pneumothorax could be present, necessitating immediate medical intervention.

Imagine you have two balloons representing the lungs, and you are listening to the air movement (breath sounds) as they inflate and deflate. If one balloon gets a hole and starts to deflate (similar to a pneumothorax causing lung collapse), you would notice that the sound of air movement becomes less pronounced or disappears altogether in the affected balloon. Similarly, reduced breath sounds upon auscultation indicate that a portion of the lung may not be participating in the breathing process, signaling a possible pneumothorax.

Normally, the lungs are kept inflated by a negative pressure within the pleural space relative to the atmospheric pressure. When there's a puncture in the pleura (from injury or other causes), air can get into the pleural space, disrupting the negative pressure and leading to lung collapse. When a lung collapses, it is unable to participate in gas exchange, and no air movement occurs in that portion of the lung. This absence of air movement is what leads to reduced or absent breath sounds upon auscultation.

 

✘Incorrect answer options:

The development of a barrel-shaped chest. While a barrel-shaped chest can indicate chronic lung conditions like COPD, it is generally not a sign of acute pneumothorax. Barrel chest occurs over a longer period and is unlikely to develop rapidly following acute chest trauma.

A decreased respiratory rate. Decreased respiratory rate might be indicative of various conditions or even medication effects but is not a direct indicator of pneumothorax. In fact, a pneumothorax often leads to an increased respiratory rate due to compromised lung function and resultant hypoxia.

Audible sucking sounds at the site of the injury. While this may suggest an "open" or "sucking" pneumothorax, it is not the most reliable indicator. Audible sucking sounds might be dramatic but are less consistent. Reduced breath sounds upon auscultation would be a more universally applicable and reliable sign to diagnose pneumothorax.

 

References

• Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.
• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care, 9th Edition. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

The drainage system has an air leak present. Continuous bubbling in the water-seal chamber of a closed chest drainage system is an abnormal finding that usually indicates the presence of an air leak somewhere in the system. This could be from the chest tube itself, from the connections between tubing, or even from the drainage system. In any case, this is a situation that warrants immediate investigation to identify and resolve the source of the leak. Failing to address this issue could compromise the patient's respiratory status, as the system will not effectively remove air from the pleural space, preventing lung re-expansion and resolving the pneumothorax.

Imagine the closed chest drainage system as a bicycle tire with a pressure gauge attached to it. The tire needs to maintain a certain pressure to work efficiently, just like the pleural space needs to maintain negative pressure for effective lung function. When everything is sealed and working correctly, the pressure gauge shows a stable reading. However, if there's a puncture or loose valve (akin to an air leak in the drainage system), you'd see signs of pressure dropping or, in our medical scenario, continuous bubbling in the water-seal chamber.

This "pressure leak" alerts you that something is off, similar to how continuous bubbling in a chest drainage system is a signal to healthcare providers that there's an issue that requires immediate attention. Just like you would inspect the tire and the valve connections for a leak, a nurse should investigate the entire closed chest drainage system to identify the source of the air leak and resolve it, thereby restoring its proper functioning.

The closed chest drainage system operates based on the principle of negative pressure in the pleural space. By maintaining a closed system, it aids in the removal of air or fluid from the pleural space, thus allowing the affected lung to re-expand. When there's an air leak, the system loses its integrity, disrupting the negative pressure needed for optimal function. Identifying the source of the leak and rectifying it ensures that the drainage system can once again function effectively, facilitating the lung's return to its normal state.

 

✘Incorrect answer options:

The chest tube is experiencing an obstruction. Continuous bubbling is not indicative of an obstruction in the chest tube. An obstruction would typically manifest as decreased or absent drainage in the collection chamber, not continuous bubbling in the water-seal chamber.

The patient is suffering from a pneumothorax. While the patient may have a pneumothorax, continuous bubbling in the water-seal chamber doesn't necessarily signify the condition of pneumothorax; it rather suggests an air leak in the drainage system. Pneumothorax would be diagnosed based on clinical and radiological findings.

The drainage system is operating as expected. Continuous bubbling is not an expected or normal finding in a closed chest drainage system. Under normal circumstances, you might see intermittent bubbling in the water-seal chamber during exhalation, coughing, or sneezing, but continuous bubbling generally indicates a problem such as an air leak.

 

References

• Lewis, S. L., Bucher, P., Heitkemper, M. M., & Harding, M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Verifying and securely taping all tube connections. Nurse Olivia should prioritize verifying and securely taping all tube connections to prevent air leaks in the system. Air leaks can compromise the integrity of the water-seal drainage system and may lead to ineffective management of the pneumothorax. A secure and air-tight system ensures that air is removed from the pleural space, allowing for optimal lung re-expansion. Additionally, air leaks can also cause inaccurate measurements of pleural drainage, potentially leading to improper clinical decisions.

Imagine you're inflating a pool float with a small hand pump. You connect various tubes to the pump, leading to the float's inflation valve. If any of these connections are loose or untaped, air will escape, making it difficult to inflate the pool float fully. You'd want to ensure all connections are tightly sealed to make the process efficient. Similarly, ensuring a secure, air-tight chest tube setup helps maintain negative pressure in the pleural space, promoting lung re-expansion and healing.

The pleural cavity normally maintains a slight negative pressure to keep the lungs inflated. A pneumothorax disrupts this balance by allowing air into the pleural space. The chest tube drainage system works by re-establishing this negative pressure, effectively pulling the air out from the pleural space. A secure connection is vital to ensure that this process works efficiently, allowing the lung tissue to adhere back to the chest wall and heal.

 

✘Incorrect answer options:

Positioning the chest drainage system lower than the patient's chest level. While it is true that the drainage system should be below the chest level to facilitate drainage by gravity, this does not specifically prevent air leaks.

Ensuring that the chest tube remains patent. A patent tube is essential for effective drainage but does not necessarily prevent an air leak from occurring at the tube connections.

Maintaining the head of the bed at a slight elevation. Elevating the head of the bed can improve respiratory mechanics but does not directly prevent air leaks from the chest tube system.

 

References

• Lewis, S. L., Bucher, P., Heitkemper, M. M., & Harding, M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

To negate the necessity for a water-seal drainage system. The Heimlich Flutter Valve serves as a one-way valve system that lets air escape from the pleural space without allowing it to re-enter. It is specifically designed for ambulatory patients with small, persistent air leaks who do not require a continuous vacuum. Replacing a Pleur-O-Vac (a traditional water-seal drainage system) with a Heimlich Flutter Valve simplifies the chest drainage process and allows the patient more mobility. The Flutter Valve is a more convenient alternative for patients with smaller pneumothoraces that still require drainage but do not necessitate the full apparatus of a water-seal drainage system like Pleur-O-Vac.

Consider your Pleur-O-Vac as a large, stationary air purifier in a room, plugged into an electrical outlet. It's bulky and not easily movable but can handle more significant issues. On the other hand, the Heimlich Flutter Valve is like a small, portable air purifier that you can carry around. It might not be as powerful, but it’s easier to manage and perfect for smaller tasks.

In the case of a small, persistent pneumothorax, a larger drainage system may be overkill. The Heimlich Flutter Valve can efficiently allow air to escape from the pleural space while preventing re-entry, thus facilitating lung re-expansion over time without requiring a water-seal or suction. It also allows the patient to be more ambulatory, improving overall comfort and mobility.

 

✘Incorrect answer options:

To avert the tube from becoming kinked. While avoiding kinks is essential for any chest tube system, switching from a Pleur-O-Vac to a Heimlich Flutter Valve primarily for this reason doesn't offer significant benefits over proper management of the existing Pleur-O-Vac system.

To obviate the need for applying a dressing. Both types of chest drainage systems will require proper dressing to maintain sterility at the insertion site. Therefore, negating the need for a dressing is not a rationale for changing from Pleur-O-Vac to Heimlich Flutter Valve.

To facilitate both air and pleural fluid drainage. While the Heimlich Flutter Valve is effective for air drainage, it is not ideal for pleural fluid drainage. If the patient also has a pleural effusion, a full water-seal drainage system like the Pleur-O-Vac would be more appropriate.

 

References

• Lewis, S. L., Bucher, P., Heitkemper, M. M., & Harding, M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Inhaled air will leak from the lung into the pleural space. Spontaneous pneumothorax occurs when air leaks into the pleural space between the lung and the chest wall. Normally, the pleural space is filled with a small amount of fluid that allows the lung to expand and retract smoothly within the chest cavity. In the case of a spontaneous pneumothorax, a rupture in the lung tissue allows inhaled air to escape into this pleural space, leading to partial or complete lung collapse. It's crucial to understand that the issue lies in the leak of air into an area where it doesn't belong, thereby disrupting the equilibrium required for normal respiration.

Think of the lung as an inflatable balloon within a protective case (the chest wall). If there's a tiny hole in the balloon, the air meant to keep it inflated escapes into the surrounding case, causing the balloon to deflate. Similarly, the lung loses its ability to remain inflated when air leaks into the pleural space.

The leaked air in the pleural space compromises the negative pressure system that normally allows for lung expansion during inhalation. As a result, the affected lung may collapse partially or fully, leading to symptoms like shortness of breath and chest pain. Treatment often involves sealing off the air leak and/or removing the leaked air to restore the appropriate pressures within the chest cavity.

 

✘Incorrect answer options:

The unaffected lung will also collapse if not treated urgently. While it is true that a pneumothorax can be a medical emergency, it is not typically the case that the unaffected lung will also collapse. Each lung is enclosed in its own pleural sac, so the effects of a pneumothorax usually remain limited to the affected lung.

The heart and major vessels will shift towards the side with the pneumothorax. This statement is incorrect. In the case of a tension pneumothorax, the heart and major vessels may actually be pushed to the opposite side (mediastinal shift), not towards the affected lung.

There exists an increased negative pressure within the chest cavity. This is misleading. While the chest cavity normally operates under negative pressure to facilitate lung expansion, a pneumothorax disrupts this balance. It doesn't increase negative pressure but rather equalizes it, making lung expansion difficult.

 

References

• Lewis, S. L., Bucher, P., Heitkemper, M. M., & Harding, M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Advocate for coughing, deep inhalations, and arm mobility on the side with the pneumothorax. Nurse Kate should encourage Ethan to cough, take deep inhalations, and move his arm on the side with the pneumothorax. These actions are essential for promoting lung expansion and preventing atelectasis (collapse of the alveoli). Coughing helps to clear secretions that could otherwise lead to infection. Deep inhalations encourage the lung to fully expand, aiding in the healing process and helping to re-establish normal respiratory function. Arm mobility can also facilitate better lung expansion by allowing the chest wall to move more freely.

Imagine the lung as a sponge inside a jar (the chest cavity). If the sponge is compressed and not allowed to expand, it won't be able to soak up water effectively. By encouraging coughing, deep breathing, and arm movement, it's like squeezing and releasing the sponge, allowing it to expand fully and soak up water (or in the case of the lung, oxygen), making it more effective in its function.

The chest tube serves to evacuate air or fluid from the pleural space, allowing the lung to re-expand. However, the mechanical action of the chest tube needs to be complemented by the patient's own respiratory efforts for optimal results. Coughing, deep breathing, and arm movement help to expand the lung tissue, improve gas exchange, and speed up the healing process.

 

✘Incorrect answer options:

Drain and quantify the fluid in the collection chamber during each shift. While it's important to monitor the drainage system, the chest tube system is usually sealed and self-draining. The nurse would not typically drain the fluid manually during each shift but would monitor it.

Provide cough suppressants at regulated times, as prescribed. Suppressing the cough would be counterproductive in this case, as coughing helps to clear secretions and promotes lung expansion, which is crucial for healing a pneumothorax.

Utilize clamps beneath the insertion site when assisting the patient to get out of bed. Clamping the chest tube is generally not recommended unless specifically instructed, as it can lead to complications like tension pneumothorax.

 

References

• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Development of a right-sided pneumothorax. Nurse Emily should immediately assess for additional signs of a right-sided pneumothorax. The absence of breath sounds in the right upper lobe along with a high-pressure alarm on the ventilator strongly suggest this condition. A pneumothorax occurs when air leaks into the space between the lung and the chest wall (pleural space), leading to a partial or complete lung collapse. The high-pressure alarm on the ventilator could be the machine's way of indicating that it's having difficulty inflating the lung, which is often the case with a pneumothorax. Prompt diagnosis and intervention are crucial to prevent complications like tension pneumothorax, which can be life-threatening.

Imagine the lung as an inflatable raft that you are trying to fill with air using a pump. If the raft has a leak (akin to a pneumothorax), the pump (akin to the ventilator) will have difficulty filling it with air and may trigger an alarm to indicate that something is wrong. In the same way, the high-pressure alarm on the ventilator and the absence of breath sounds in the right upper lobe are indicators that air is leaking into the pleural space, causing the lung to collapse partially or entirely.

In a healthy respiratory system, the pleural space is at a slightly negative pressure compared to atmospheric pressure, which helps to keep the lungs inflated. When a pneumothorax occurs, air enters the pleural space, converting it from negative to positive pressure. This positive pressure opposes lung expansion during inspiration, leading to partial or complete lung collapse. The ventilator's high-pressure alarm goes off because it detects increased resistance while trying to inflate the lung, serving as a warning sign of possible pneumothorax.

 

✘Incorrect answer options:

Acute Respiratory Distress Syndrome (ARDS). While ARDS can cause difficulty in ventilation and could theoretically trigger a high-pressure alarm, the absence of breath sounds in one specific lobe is more indicative of a localized issue like pneumothorax rather than a diffuse problem like ARDS.

Dislocation of the endotracheal tube. If the tube were dislocated, you would likely notice problems in both lungs, not just one lobe. The specific absence of breath sounds in the right upper lobe suggests a localized issue.

Presence of a pulmonary embolism. While a pulmonary embolism is a severe condition that can cause ventilatory and circulatory issues, it wouldn't typically cause an absence of breath sounds in just one lobe of the lung. Furthermore, a pulmonary embolism would not typically trigger a high-pressure alarm on a ventilator.

 

References

• Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.
• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care, 9th Edition. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Lack of fluctuation in the water-seal chamber when no suction is applied. The absence of fluctuation in the water-seal chamber when no suction is applied is indicative that the lung has successfully re-expanded and there is no more air leaking into the pleural space. Essentially, the "tiding" or "fluctuations" in the water-seal chamber reflect the intrathoracic pressure changes occurring during inhalation and exhalation. When the lung has re-expanded and sealed itself, these fluctuations will stop, indicating that the pneumothorax has resolved and it may be safe to remove the chest tube after confirming with additional diagnostics such as a chest X-ray.

Think of a leaky boat with a bilge pump actively pumping water out. When the boat is still taking in water (analogous to air leaking into the pleural space), you would see the water level in the bilge pump container (analogous to the water-seal chamber) fluctuating. Once the leak is sealed, the water level in the container would stabilize, indicating that it’s safe to turn off the bilge pump (akin to removing the chest tube).

The water-seal chamber acts as a one-way valve, allowing air and fluid to escape from the pleural space but preventing anything from entering back in. The fluctuation, or "tidaling," of the water level corresponds to the patient's breathing cycle. Lack of fluctuation when the suction is off can mean that the hole in the lung has sealed and the lung has fully re-expanded, thereby equilibrating the pressure in the pleural space with atmospheric pressure.

 

✘Incorrect answer options:

Normal levels in the arterial blood gas (ABG) report. While normal ABG levels might indicate effective gas exchange, they are not the definitive measure to decide if a chest tube can be removed. It's possible to have near-normal ABGs with a small, unresolved pneumothorax.

Continued evidence on the chest X-ray that the lung is 35% deflated. This is an indication that the chest tube should remain in place, not that it should be removed. A deflated lung suggests that the pneumothorax has not fully resolved, and further intervention or monitoring is necessary.

Significant drainage being noted from the chest tube. This is also an incorrect answer. Significant drainage could indicate that there is still an issue needing resolution, such as continued bleeding or infection, and the chest tube should not be removed.

 

References

• Lewis, S. L., Bucher, P., Heitkemper, M. M., & Harding, M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Intense shortness of breath. Intense shortness of breath is a hallmark symptom of pneumothorax, which occurs when air leaks into the space between the lung and the chest wall, causing the lung to collapse. This compromises the lung's ability to expand and contract, leading to decreased oxygen exchange and resulting in shortness of breath. Nurse Emily should emphasize the importance of seeking immediate medical attention if Sophia experiences intense shortness of breath, as this could indicate a recurrence of pneumothorax or another serious respiratory issue.

Think of your lung as a tire on a car. Normally, the tire is fully inflated, allowing the car to run smoothly. If the tire gets punctured, it starts to deflate, affecting the car's performance. Similarly, when a pneumothorax occurs, the lung "deflates," making it difficult to breathe. Just as you would pull over immediately to fix a flat tire, experiencing intense shortness of breath is a sign that you need to seek medical attention right away.

The lungs are vital for oxygenating the blood, which is then circulated to various tissues and organs. When a pneumothorax occurs, the affected lung cannot fully expand, leading to hypoxia or low levels of oxygen in the blood. This triggers the sensation of shortness of breath as the body attempts to compensate for the lack of oxygen. The condition can worsen rapidly and may lead to respiratory failure if not promptly addressed.

 

✘Incorrect answer options:

Frequent episodes of heart palpitations. While heart palpitations can be concerning, they are generally not a direct symptom of pneumothorax. Palpitations are more commonly associated with cardiac issues or anxiety and would not be the primary symptom to watch for in the context of a recent pneumothorax.

Pain below the breastbone. Pain below the breastbone is often related to gastrointestinal issues or cardiac problems rather than a pneumothorax. While chest pain can sometimes accompany a pneumothorax, it is usually localized to the side of the affected lung rather than below the breastbone.

Feeling dizzy upon standing up. Dizziness upon standing is typically related to orthostatic hypotension or other cardiovascular issues. While it's a concerning symptom, it is not directly indicative of a pneumothorax and would not be the primary symptom to monitor for in this case.

 

References

• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Take no action, as this is an expected observation. In a chest drainage system with active suction, continuous, gentle bubbling in the suction control chamber is a normal and expected finding. The bubbling indicates that the suction is being applied to the system, helping to evacuate air, blood, or other fluids from the pleural space, and thereby facilitating lung re-expansion. The bubbling should be gentle; if it is vigorous, that could indicate that the suction is set too high, which could potentially lead to complications. Therefore, in this scenario, Nurse Kim should take no action regarding the bubbling, as it is indicative of the system functioning as it should.

Think of the suction control chamber as a fish tank's air pump. When you see bubbles continuously coming from the pump's air stone submerged in the water, you understand that the pump is working and aerating the tank properly. Similarly, continuous gentle bubbling in the suction control chamber of a chest drainage system indicates that the suction is functioning effectively, helping to remove air or fluids from the pleural space and allow the lungs to properly expand.

The chest tube serves as a conduit to relieve the pneumothorax, a condition where air has entered the pleural space, causing lung collapse. Normally, the pleural space has a negative pressure relative to atmospheric pressure, which helps the lungs stay inflated. In pneumothorax, this pressure balance is disrupted, and the chest tube helps by allowing air or fluid to escape, re-establishing a more normal pressure differential. The suction control chamber assists in this by exerting a controlled suction force, helping to actively remove air or fluids. The bubbling ensures that this suction is being effectively applied.

 

✘Incorrect answer options:

Examine the system for an air leak as the bubbling should only be intermittent. This statement is incorrect because continuous, gentle bubbling is expected when suction is being applied. Intermittent bubbling in the water seal chamber, not the suction control chamber, may be seen when there is no air leak.

Immediately clamp the chest tube and alert the healthcare provider. This action would be inappropriate under the given conditions. Clamping the chest tube without a proper indication can lead to complications, including tension pneumothorax, a life-threatening situation. If bubbling was observed in the water seal chamber rather than the suction control chamber, then it would be time to check for air leaks, but this is not the case here.

Elevate the suction pressure to make the bubbling more vigorous. This is not advisable because overly vigorous bubbling could imply excessive suction, which may lead to complications like tissue trauma. The suction level should be set according to healthcare provider's orders, and excessive suction can damage tissues and delay healing.

 

References

• Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.
• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care, 9th Edition. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Shift of the mediastinum. Nurse Zoe should be most vigilant in monitoring for a shift of the mediastinum, as this could indicate a life-threatening tension pneumothorax. A flail chest with multiple rib fractures can compromise the integrity of the chest wall, leading to the accumulation of air in the pleural space. This air can exert pressure on the mediastinum, which houses critical structures like the heart and major blood vessels, and shift it to the opposite side. This shift can compress the vena cava and other major vessels, leading to decreased venous return to the heart and subsequent cardiovascular collapse if not promptly addressed.

Think of the mediastinum as a central control room in a building, housing all the essential electrical and plumbing systems. If a wall in the building (the chest wall) is severely damaged, it could cause a shift in the control room's position. This shift could disrupt the essential systems (like the heart and major blood vessels), causing a domino effect that jeopardizes the entire building (the body).

The mediastinum contains the heart, trachea, esophagus, and major blood vessels. A shift in its position due to tension pneumothorax can lead to compression of these structures. This can result in reduced venous return to the heart, decreased cardiac output, and hypoxia, which are life-threatening if not immediately corrected. The shift is often diagnosed through imaging studies like a chest X-ray and requires immediate decompression to relieve the pressure.

 

✘Incorrect answer options:

Pericardial tamponade. While pericardial tamponade is a serious condition involving the accumulation of fluid in the pericardial sac, it is not the most likely complication to arise from a flail chest with multiple rib fractures. Pericardial tamponade is more commonly associated with penetrating chest injuries rather than blunt trauma like a flail chest.

Open pneumothorax. An open pneumothorax occurs when there is an open wound in the chest wall, allowing air to enter the pleural space. While serious, this is not the most immediate concern for a flail chest, which is a closed injury. An open pneumothorax would require a penetrating injury to the chest wall.

Laceration of the trachea. Tracheal laceration is a severe but rare complication that would more likely result from penetrating trauma or surgical procedures rather than a blunt trauma like a flail chest. It would present with different symptoms, such as subcutaneous emphysema and difficulty breathing, but is not the primary concern in this scenario.

 

References

• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Preparing the client for chest tube insertion. In the case of a newly diagnosed spontaneous pneumothorax with acute, stabbing chest pain and anxiety, the priority intervention would be to prepare Ava for chest tube insertion. A chest tube is essential for evacuating the air that has leaked into the pleural space, causing the lung to collapse. This will help in re-expanding the lung, improving respiratory function, and subsequently alleviating the acute pain and anxiety that Ava is experiencing. The procedure is often urgent, especially if the pneumothorax is affecting Ava's respiratory status, so prompt preparation is crucial.

Imagine your lung as a sail on a boat. Normally, the sail catches the wind and helps the boat move smoothly. If there's a tear in the sail (akin to a pneumothorax), it won't catch the wind properly, affecting the boat's ability to move. Inserting a chest tube is like patching up that tear in the sail. By removing the trapped air (or fixing the tear), the sail (lung) can function properly again, allowing the boat (your body) to move (breathe) smoothly.

The chest tube serves to remove the trapped air from the pleural space, allowing the lung to re-expand and restore normal pressure within the chest cavity. This will improve gas exchange in the alveoli, leading to better oxygenation of the blood. As the lung re-expands, the acute, stabbing pain that Ava is experiencing due to the tension on the pleura will also be relieved, reducing her anxiety and improving her overall condition.

 

✘Incorrect answer options:

Administering intravenous analgesics as prescribed. While pain management is important, it is not the priority in this situation. Administering analgesics will not address the underlying issue of the collapsed lung, which requires immediate intervention.

Assisting the client into Fowler's position. Although positioning can help improve lung expansion, it is not sufficient to treat a pneumothorax. A more definitive intervention, such as chest tube insertion, is required to resolve the issue.

Administering subcutaneous heparin. Heparin is an anticoagulant and is not indicated for the treatment of pneumothorax. Its administration would not alleviate the acute symptoms Ava is experiencing and could introduce unnecessary risks like bleeding.

 

References

• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Respiratory acidosis, atelectasis, and hypostatic pneumonia. Patients who are recumbent and immobilized for extended periods are at increased risk for respiratory complications due to decreased lung expansion and ineffective cough. This can lead to the accumulation of carbon dioxide (respiratory acidosis), collapse of the alveoli (atelectasis), and pooling of secretions that can cause infection (hypostatic pneumonia).

Imagine your lungs as balloons that need to be fully inflated and deflated regularly. If you're lying down and not moving for a long time, it's like not fully inflating the balloons. This can lead to them sticking together (atelectasis), not getting rid of waste air properly (respiratory acidosis), and collecting dirt (hypostatic pneumonia).

• Respiratory Acidosis: Immobility leads to shallow breathing and poor gas exchange, causing an accumulation of carbon dioxide in the blood.
• Atelectasis: Lack of movement and deep breathing can cause alveoli to collapse, reducing the surface area for gas exchange.
• Hypostatic Pneumonia: Gravity causes secretions to pool at the base of the lungs, creating a breeding ground for bacteria.

 

✘Incorrect answer options:

Kussmaul's respirations and hypoventilation. Kussmaul's respirations are deep and labored breathing usually associated with metabolic acidosis, not necessarily with immobility. Hypoventilation is a risk but it leads to respiratory acidosis, not Kussmaul's respirations.

Apneustic breathing, atypical pneumonia, and respiratory alkalosis. Apneustic breathing is a neurological issue and not directly related to immobility. Atypical pneumonia and respiratory alkalosis are also not directly related to being recumbent and immobilized.

Cheyne-Stokes respirations and spontaneous pneumothorax. Cheyne-Stokes is often related to heart failure or brain injury. Spontaneous pneumothorax is generally not caused by immobility but by rupture of air-filled blisters.

 

References

• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Presence of a pericardial tamponade. The combination of a lack of fluid or air in the thoracic cavity (ruled out by thoracentesis), unresponsive vital signs despite IV fluid and blood administration, and an elevated central venous pressure (CVP) of 20 cm H₂O strongly suggests pericardial tamponade. In this condition, fluid accumulates in the pericardial sac around the heart, leading to impaired cardiac function and elevated venous pressures. Fluid resuscitation would typically improve vitals, but if tamponade is present, this measure will be ineffective due to the mechanical obstruction caused by the fluid around the heart.

Imagine the heart as a water pump in a garden. If you wrap a tight plastic bag around the pump, it will have difficulty pushing water out into the garden, just as the heart struggles to pump blood effectively when it's compressed by fluid in a pericardial tamponade. No matter how much water you add to the garden's source (akin to administering IV fluids), the pump can't work correctly until you remove the plastic bag (i.e., drain the pericardial fluid).

Pericardial tamponade exerts external pressure on the myocardium, limiting ventricular diastolic filling. This results in reduced cardiac output, manifesting as hypotension and tachycardia. Elevated CVP, seen in this case, is a classic indicator of this condition as venous return is hampered by the impaired pumping action of the heart. Immediate intervention usually involves pericardiocentesis to relieve the pressure on the heart.

 

✘Incorrect answer options:

Rupture of the diaphragm. A diaphragmatic rupture would be more likely to present with abdominal symptoms and would not cause the elevated CVP readings seen here. Also, it would likely be visualized on imaging studies.

Development of a hemothorax. This condition involves the accumulation of blood in the pleural cavity and would typically be identified during thoracentesis. It also wouldn't typically cause an elevated CVP unless it led to significant loss of blood volume, which has been ruled out by the ineffective IV fluid and blood resuscitation.

Occurrence of a spontaneous pneumothorax. This situation would generally be identified via thoracentesis or imaging and would not typically cause an elevated CVP. The presence of pneumothorax would also typically lead to impaired oxygenation, which can be somewhat responsive to oxygen therapy.

 

References

• Lewis, S. L., Bucher, P., Heitkemper, M. M., & Harding, M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

"The tube will extract excess air from your chest cavity." The primary function of a chest tube in the context of a spontaneous pneumothorax is to remove excess air that has entered the pleural space. This air disrupts the normal negative pressure that helps the lungs to stay inflated. By removing the air, the chest tube allows the lungs to re-expand, restoring proper lung function. This is essential for alleviating symptoms like shortness of breath and promoting faster healing.

Imagine your lung as a balloon inside a jar (your chest cavity). Normally, the balloon stays inflated because the jar is sealed tight. However, if there's a leak (like a spontaneous pneumothorax), air enters the jar, and the balloon starts to deflate. The chest tube acts like a vacuum cleaner that sucks out the extra air from the jar, allowing the balloon to inflate back to its normal size.

The pleural space between the lung and chest wall is a sealed system that usually maintains a slightly negative pressure. This negative pressure is vital for keeping the lungs inflated. A spontaneous pneumothorax occurs when there is a rupture in the lung tissue, allowing air to escape into the pleural space. This disrupts the pressure dynamics, causing the lung to collapse partially or entirely. The chest tube helps in re-establishing the negative pressure by removing the trapped air, allowing the lung to re-expand.

 

✘Incorrect answer options:

"The tube will plug the puncture in your lung". A chest tube does not plug punctures in the lung tissue. Its primary role is to remove excess air or fluids from the pleural space, allowing for lung re-expansion. Sealing a punctured lung would require other interventions, possibly including surgery.

"The tube will regulate the volume of air entering your chest". This explanation is misleading. The chest tube is not designed to regulate the volume of air entering the chest; it is designed to remove excess air or fluids to restore normal lung function.

"The tube will siphon off fluid from your chest". While it's true that chest tubes can be used to drain fluids in conditions like pleural effusion or hemothorax, in the context of a spontaneous pneumothorax, the primary function is to remove excess air, not fluid.

 

References

• Lewis, S. L., Bucher, P., Heitkemper, M. M., & Harding, M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.