Chapter 30: Pneumothorax

Question 1

A patient with a suspected pneumothorax is being assessed. Which of the following findings is most indicative of a pneumothorax?

A. Subcutaneous emphysema
B. Tracheal deviation
C. Absence of breath sounds over the affected area
D. Hyperresonance on percussion

Answer 1

C. Absence of breath sounds over the affected area

Rationale: Breath sounds are absent over the affected area in a pneumothorax due to the presence of air in the pleural space preventing lung expansion.

Question 2

Which of the following would be a likely initial clinical manifestation of a small pneumothorax?

A. Severe chest pain
B. Mild tachycardia and dyspnea
C. Cyanosis
D. Hypotension

Answer 2

B. Mild tachycardia and dyspnea

Rationale: A small pneumothorax may present with mild tachycardia and dyspnea as the initial symptoms.

Question 3

What is the primary cause of a lung collapse in a pneumothorax?

A. Air entering the pleural cavity
B. Infection
C. Accumulation of fluid in the pleural space
D. Increased thoracic pressure from a cough

Answer 3

A. Air entering the pleural cavity

Rationale: A pneumothorax is caused by air entering the pleural cavity, which disrupts the negative pressure needed to keep the lungs inflated, leading to lung collapse.

Question 4

A patient presents with a penetrating chest wound described as a “sucking chest wound.” What is the immediate concern for this patient?

A. Risk of infection
B. Fluid accumulation in the pleural space
C. Hypoxia due to decreased alveolar ventilation
D. Air entering the pleural space during inspiration

Answer 4

D. Air entering the pleural space during inspiration

Rationale: A “sucking chest wound” allows air to enter the pleural space during inspiration, which can cause a pneumothorax and subsequent lung collapse.

Question 5

What diagnostic test is commonly used to confirm the presence of a pneumothorax?

A. MRI
B. CT Scan
C. Chest X-ray
D. Ultrasound

Answer 5

C. Chest X-ray

Rationale: A chest X-ray is commonly used to confirm the presence of a pneumothorax by showing air or fluid in the pleural space and reduced lung volume.

Question 6

A patient with a larger pneumothorax presents with respiratory distress. Which of the following signs would you expect to find upon assessment?

A. Decreased respiratory rate
B. Shallow, rapid respirations
C. Normal oxygen saturation
D. Eupnea

Answer 6

B. Shallow, rapid respirations

Rationale: A larger pneumothorax can cause significant respiratory distress, which often manifests as shallow, rapid respirations.

Question 7

Which of the following best describes the pleural space in the context of a normal functioning respiratory system?

A. Filled with air to facilitate lung movement
B. A space with positive pressure
C. Contains a few milliliters of lubricating fluid to reduce friction
D. The main site of gas exchange in the lungs

Answer 7

C. Contains a few milliliters of lubricating fluid to reduce friction

Rationale: The pleural space normally contains a few milliliters of lubricating fluid to reduce friction when the tissues move.

Question 8

What type of pneumothorax can occur without any external wound?

A. Open pneumothorax
B. Closed pneumothorax
C. Tension pneumothorax
D. Spontaneous pneumothorax

Answer 8

B. Closed pneumothorax

Rationale: A closed pneumothorax occurs without any external wound, whereas an open pneumothorax involves air entering through an opening in the chest wall.

Question 9

A nurse is caring for a young, tall, thin male who is a smoker and has a history of asthma. Which of the following conditions is he at an increased risk for?

A. Spontaneous pneumothorax
B. Pleural effusion
C. Pulmonary embolism
D. Pneumonia

Answer 9

A. Spontaneous pneumothorax

Rationale: The patient’s risk factors, such as being tall and thin, male gender, smoking, and having a history of asthma, increase the likelihood of spontaneous pneumothorax due to the formation of small blebs on the lung surface.

Question 10

A patient with chronic obstructive pulmonary disease (COPD) is diagnosed with a spontaneous pneumothorax. Which of the following is the most likely cause of the pneumothorax?

A. Rupture of small blebs on the lung surface
B. A severe asthma attack
C. An underlying pneumonia infection
D. Pulmonary embolism

Answer 10

A. Rupture of small blebs on the lung surface

Rationale: In COPD patients, spontaneous pneumothorax often occurs due to the rupture of small blebs, which are air-filled sacs that can form on the surface of the lungs.

Question 11

A nurse is teaching a patient with a history of spontaneous pneumothorax about risk factors. Which statement by the patient indicates a need for further education?

A. “I should avoid smoking to prevent bleb formation.”
B. “Being tall and thin can increase my risk for pneumothorax.”
C. “I am at higher risk because I have asthma.”
D. “A previous spontaneous pneumothorax doesn’t increase my risk for future ones.”

Answer 11

D. “A previous spontaneous pneumothorax doesn’t increase my risk for future ones.”

Rationale: Having a previous spontaneous pneumothorax actually increases the risk of having another one, so the statement shows a misunderstanding and requires further education.

Question 12

A 25-year-old male patient with no significant medical history presents with sudden chest pain and shortness of breath. He is tall and thin and has been smoking for several years. What is the most likely diagnosis?

A. Spontaneous pneumothorax
B. Acute asthma exacerbation
C. Myocardial infarction
D. Tension pneumothorax

Answer 12

A. Spontaneous pneumothorax

Rationale: This patient’s sudden chest pain and shortness of breath, combined with risk factors such as being tall and thin, smoking, and male gender, suggest spontaneous pneumothorax, especially since he has no significant medical history.

Question 13

A nurse is monitoring a patient with spontaneous pneumothorax who has been treated with oxygen therapy and observation. Which of the following would indicate that the patient’s condition is worsening?

A. Increase in respiratory rate and effort
B. Decrease in oxygen saturation
C. Sudden onset of sharp, localized chest pain
D. All of the above

Answer 13

D. All of the above

Rationale: Worsening spontaneous pneumothorax is indicated by increased respiratory rate and effort, decreased oxygen saturation, and sharp chest pain, as these signs suggest that the pneumothorax is not resolving and may require further intervention.

Question 14

A patient undergoing subclavian catheter insertion develops a pneumothorax. The nurse recognizes that this type of pneumothorax is most likely classified as:

A. Spontaneous pneumothorax
B. Traumatic pneumothorax
C. Iatrogenic pneumothorax
D. Tension pneumothorax

Answer 14

C. Iatrogenic pneumothorax

Rationale: Iatrogenic pneumothorax occurs as a result of medical procedures, such as subclavian catheter insertion, which can inadvertently puncture or lacerate the lung.

Question 15

A patient undergoing mechanical ventilation is at increased risk for which of the following types of pneumothorax?

A. Spontaneous pneumothorax
B. Iatrogenic pneumothorax
C. Traumatic pneumothorax
D. Tension pneumothorax

Answer 15

B. Iatrogenic pneumothorax

Rationale: Iatrogenic pneumothorax can result from barotrauma due to excessive ventilatory pressures during mechanical ventilation, causing alveolar rupture and subsequent pneumothorax.

Question 16

A nurse is monitoring a patient who is undergoing a transthoracic needle aspiration. Which of the following is the nurse’s priority action if a pneumothorax is suspected?

A. Administer pain medication
B. Notify the healthcare provider immediately
C. Apply oxygen via a non-rebreather mask
D. Prepare for chest tube insertion

Answer 16

B. Notify the healthcare provider immediately

Rationale: If a pneumothorax is suspected during or after a transthoracic needle aspiration, it is critical to notify the healthcare provider immediately for further evaluation and possible intervention.

Question 17

A patient who recently underwent a pleural biopsy develops a pneumothorax. Which of the following is the most common cause of iatrogenic pneumothorax in this patient?

A. Laceration of the lung during the biopsy

B. Excessive ventilatory pressures used during the procedure

C. Air entering the pleural space from a tear in the esophagus

D. Infection from the biopsy causing alveolar rupture

Answer 17

A. Laceration of the lung during the biopsy

Rationale: Pleural biopsy can result in iatrogenic pneumothorax if the lung is accidentally lacerated or punctured during the procedure.

Question 18

A patient with a history of esophageal surgery is at risk for iatrogenic pneumothorax due to which of the following scenarios?

A. Tearing of the esophageal wall during gastric tube insertion

B. Excessive ventilatory pressure during anesthesia

C. Trauma during chest tube insertion

D. Barotrauma from mechanical ventilation

Answer 18

A. Tearing of the esophageal wall during gastric tube insertion

Rationale: Iatrogenic pneumothorax can occur when the esophageal wall is torn during gastric tube insertion, allowing air to enter the mediastinum and pleural space.

Question 19

A nurse is caring for a patient with a tension pneumothorax. Which of the following is the priority intervention for this condition?

A. Administer oxygen therapy
B. Start an intravenous line to administer fluids
C. Perform needle decompression to relieve pressure
D. Insert a chest tube to drain the pleural space

Answer 19

C. Perform needle decompression to relieve pressure

Rationale: Tension pneumothorax is a medical emergency requiring immediate intervention to relieve the pressure in the pleural space. Needle decompression is the first priority to restore pressure balance and prevent cardiovascular collapse.

Question 20

A patient with a tension pneumothorax is exhibiting signs of tracheal deviation and severe respiratory distress. The nurse understands that this is due to:

A. Increased venous return from the unaffected side
B. Pressure on the heart and great vessels from the trapped air
C. Decreased pressure on the unaffected lung
D. Rapid oxygenation of the affected lung

Answer 20

B. Pressure on the heart and great vessels from the trapped air

Rationale: In a tension pneumothorax, air enters the pleural space but cannot escape, causing pressure to build up. This pressure compresses the heart and great vessels, causing the mediastinum to shift and affecting both cardiac and respiratory function.

Question 21

A nurse is assessing a patient with suspected tension pneumothorax. Which of the following signs is the most concerning and requires immediate intervention?

A. Increased neck vein distention
B. Decreased breath sounds on the affected side
C. Severe dyspnea and marked tachycardia
D. Tracheal deviation to the unaffected side

Answer 21

D. Tracheal deviation to the unaffected side

Rationale: Tracheal deviation is a late sign of tension pneumothorax and indicates severe pressure in the pleural space. Immediate intervention is necessary to relieve the pressure and prevent further complications.

Question 22

A nurse is caring for a patient who sustained a trauma and is at risk for developing a tension pneumothorax. Which of the following actions may cause or exacerbate tension pneumothorax in this patient?

A. Clamping a chest tube in place
B. Administering high-flow oxygen
C. Inserting a nasogastric tube
D. Elevating the head of the bed

Answer 22

A. Clamping a chest tube in place

Rationale: Clamping a chest tube can obstruct the pleural drainage, leading to the accumulation of air and causing or exacerbating a tension pneumothorax, which can result in increased pressure and cardiovascular compromise.

Question 23

A patient with a tension pneumothorax is being prepared for needle decompression. The nurse prepares to insert the needle in which location?

A. Above the fifth intercostal space, midaxillary line
B. Below the seventh rib, anterior axillary line
C. Second intercostal space, midclavicular line
D. Fifth intercostal space, anterior axillary line

Answer 23

C. Second intercostal space, midclavicular line

Rationale: The appropriate location for needle decompression in a tension pneumothorax is the second intercostal space, midclavicular line, on the affected side. This allows for effective release of pressure in the pleural space.

Question 24

A nurse is monitoring a patient after successful needle decompression for tension pneumothorax. Which of the following findings would indicate that the patient is stabilizing?

A. Decreased neck vein distention
B. Tracheal deviation to the affected side
C. Increased breath sounds on the affected side
D. Decreased tachycardia and improved oxygenation

Answer 24

D. Decreased tachycardia and improved oxygenation

Rationale: After needle decompression, the reduction in intrapleural pressure should improve the patient’s oxygenation and decrease tachycardia, indicating that cardiovascular and respiratory function is stabilizing.

Question 25

A patient presents with a traumatic hemothorax following a motor vehicle accident. Which of the following is the priority intervention?

A. Administer pain medication

B. Prepare for chest tube insertion

C. Start intravenous fluids for hydration

D. Monitor for signs of infection

Answer 25

B. Prepare for chest tube insertion

Rationale: The priority intervention for a traumatic hemothorax is the insertion of a chest tube to evacuate the blood from the pleural space and prevent complications such as respiratory distress or hypovolemic shock.

Question 26

A patient with hemothorax is receiving autotransfusion of blood drained from the chest tube. What is the nurse’s primary concern during this procedure?

A. Risk of infection from the blood transfusion
B. Proper setup of the autotransfusion equipment
C. Potential for hemolysis of the transfused blood
D. Risk of fluid overload from reinfusion

Answer 26

B. Proper setup of the autotransfusion equipment

Rationale: The nurse’s primary concern is ensuring that the autotransfusion equipment is properly set up to safely reinfuse blood into the patient. Incorrect setup can lead to complications such as contamination or incorrect blood volume being reinfused.

Question 27

A nurse is caring for a patient with hemothorax who has a chest tube in place. Which of the following findings indicates that the patient may be experiencing a complication?

A. Constant bubbling in the chest tube drainage system
B. Decreased drainage of blood from the chest tube
C. Absence of breath sounds on the affected side
D. Increased blood drainage from the chest tube

Answer 27

D. Increased blood drainage from the chest tube

Rationale: Increased blood drainage from the chest tube may indicate ongoing bleeding or re-accumulation of blood in the pleural space, which could lead to hemodynamic instability and requires immediate evaluation.

Question 28

A patient with hemothorax is being monitored after chest tube insertion. Which of the following findings would be most concerning and require immediate intervention?

A. Blood-tinged drainage in the chest tube
B. Mild pain at the chest tube insertion site
C. A drop in hemoglobin and hematocrit levels
D. A decrease in the amount of drainage from the chest tube

Answer 28

C. A drop in hemoglobin and hematocrit levels

Rationale: A significant drop in hemoglobin and hematocrit levels suggests ongoing internal bleeding or insufficient evacuation of blood from the pleural space, which may require further intervention such as surgical evaluation.

Question 29

A patient with hemothorax is being prepared for chest tube insertion. Which of the following is the nurse’s priority action before the procedure?

A. Administer pain medication as ordered
B. Prepare the patient for autotransfusion of the blood
C. Obtain a chest x-ray to confirm the location of the hemothorax
D. Ensure that the chest tube drainage system is set up and ready

Answer 29

D. Ensure that the chest tube drainage system is set up and ready

Rationale: The nurse’s priority action before chest tube insertion is to ensure that the chest tube drainage system is set up and ready to collect the blood drained from the pleural space. This is necessary to prevent further complications and to provide a proper drainage mechanism.

Question 30

A patient is diagnosed with chylothorax following a traumatic injury. Which of the following interventions is likely to be part of the conservative treatment plan?

A. Insertion of a chest tube for drainage
B. Immediate thoracic duct ligation
C. High-dose corticosteroid therapy
D. Radiation therapy to the pleural space

Answer 30

A. Insertion of a chest tube for drainage

Rationale: Conservative treatment for chylothorax often involves chest tube insertion for drainage of the milky white lymphatic fluid, bowel rest, and dietary changes. This is typically the first line of treatment before considering more invasive measures like surgery.

Question 31

A patient with chylothorax is receiving octreotide therapy. What is the primary action of this medication in the management of chylothorax?

A. It decreases the production of lymphatic fluid.

B. It increases the flow of lymphatic fluid to the thoracic duct.

C. It helps in the closure of the pleural space.

D. It reduces the secretion of gastric acids.

Answer 31

A. It decreases the production of lymphatic fluid.

Rationale: Octreotide works by reducing the flow of lymphatic fluid, which can help manage chylothorax by decreasing the volume of milky fluid accumulating in the pleural space.

Question 32

A nurse is monitoring a patient with chylothorax who is receiving conservative treatment, including chest tube drainage and bowel rest. Which of the following would be most important for the nurse to monitor during this treatment plan?

A. Serum lipid levels
B. Respiratory rate and oxygen saturation
C. Liver function tests
D. Serum potassium levels

Answer 32

B. Respiratory rate and oxygen saturation

Rationale: The nurse should monitor respiratory status closely, including respiratory rate and oxygen saturation, as chylothorax can impair lung expansion and oxygenation due to the accumulation of lymphatic fluid in the pleural space.

Question 33

A patient with chylothorax has been placed on a low-fat diet as part of their treatment. What is the primary reason for this dietary change?

A. To reduce the production of chyle by the lymphatic system
B. To prevent malnutrition due to reduced calorie intake
C. To stimulate the healing of the thoracic duct
D. To prevent fluid overload from the chest tube drainage

Answer 33

A. To reduce the production of chyle by the lymphatic system

Rationale: A low-fat diet helps decrease the production of chyle, which is high in lipids and contributes to the accumulation of lymphatic fluid in the pleural space. This can reduce the volume of fluid in the pleural cavity.

Question 34

A patient with chylothorax undergoes thoracic duct ligation as part of their treatment plan. What is the primary goal of this surgical intervention?

A. To seal off the pleural space and prevent air accumulation
B. To decrease the production of fluid in the peritoneal cavity
C. To stop the leakage of lymphatic fluid into the pleural space
D. To remove the infected portion of the lung

Answer 34

C. To stop the leakage of lymphatic fluid into the pleural space

Rationale: The goal of thoracic duct ligation is to stop the leakage of lymphatic fluid into the pleural space, which is the underlying cause of chylothorax. This surgical intervention is typically considered when conservative treatments fail.

Question 35

A nurse is providing education to a patient with a spontaneous pneumothorax. Which statement by the nurse is appropriate regarding the possible resolution of the condition?

A. “The pneumothorax will definitely require chest tube insertion.”

B. “Your condition may resolve on its own without treatment.”

C. “You will need surgery to repair the lung immediately.”

D. “You must remain on a ventilator for at least 24 hours.”

Answer 35

B. “Your condition may resolve on its own without treatment.”

Rationale: In cases of spontaneous pneumothorax, if the patient is stable and the pneumothorax is minimal, it may resolve on its own without the need for invasive treatment. Conservative management and observation are often sufficient.

Question 36

A patient with an open pneumothorax has a large, impaled object in the chest wound. The pre-hospital care provider stabilizes the object with a bulky dressing. What is the rationale for this intervention?

A. To prevent further damage to the lung tissue.
B. To reduce the risk of infection at the wound site.
C. To prevent the object from moving and causing further injury.
D. To allow the wound to heal before transport.

Answer 36

C. To prevent the object from moving and causing further injury.

Rationale: Stabilizing the impaled object with a bulky dressing helps prevent it from shifting, which could cause further damage to the lung or other organs. The object should not be removed in the pre-hospital setting.

Question 37

A patient with a pneumothorax is stable and is not experiencing significant symptoms. Which of the following actions should the nurse prioritize?

A. Prepare the patient for chest tube insertion.

B. Administer oxygen to the patient to improve oxygenation.

C. Reassure the patient that no immediate invasive intervention is required.

D. Initiate continuous cardiac monitoring.

Answer 37

C. Reassure the patient that no immediate invasive intervention is required.

Rationale: If the patient is stable and the pneumothorax is minimal, the nurse should reassure the patient that invasive interventions may not be necessary and that the condition may resolve on its own with monitoring.

Question 38

A pre-hospital care provider encounters a patient with a penetrating chest wound. What is the most appropriate action to take before transport to the hospital?

A. Remove the impaled object if it is causing respiratory distress.

B. Apply a non-occlusive dressing to the wound.

C. Secure the chest wound with a sterile bandage and no dressing.

D. Apply an occlusive dressing secured on three sides to the wound.

Answer 38

D. Apply an occlusive dressing secured on three sides to the wound.

Rationale: The occlusive dressing prevents air from entering the pleural space during inspiration, while allowing air to escape during expiration. This helps manage an open chest wound until the patient can be transported to a medical facility for further care.

Question 39

A patient with a pneumothorax presents with mild dyspnea and stable vital signs. The healthcare provider decides to monitor the patient and not initiate any invasive treatment. Which of the following factors most likely influenced this decision?

A. The size of the pneumothorax is minimal.

B. The patient has a history of COPD.

C. The patient is experiencing severe chest pain.

D. The patient has poor renal function.

Answer 39

A. The size of the pneumothorax is minimal.

Rationale: A minimal pneumothorax with stable vital signs and mild symptoms may resolve on its own without the need for invasive treatment. The decision to monitor is based on the size of the pneumothorax and the patient’s hemodynamic stability.

Question 40

A patient with a pneumothorax is being treated in the emergency department. The healthcare provider has instructed the nurse to apply a three-sided occlusive dressing to the chest wound. What is the purpose of this dressing

A. To prevent further bleeding from the chest wound

B. To allow air to enter the pleural space during expiration

C. To prevent air from entering the pleural space during inspiration

D. To provide a sterile barrier over the open wound

Answer 40

C. To prevent air from entering the pleural space during inspiration

Rationale: A three-sided occlusive dressing allows air to escape from the wound during expiration but prevents air from entering the pleural space during inspiration, which is important in preventing the pneumothorax from worsening.

Question 41

After change-of-shift report, which patient would the nurse assess first?

a. A 40-yr-old with a pleural effusion who reports severe stabbing chest pain

b. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet

c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion

d. A 28-yr-old with a history of a lung transplant 1 month ago and a fever of 101F (38.3C)

Answer 41

c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion

Rationale: The patient‘s history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.

Question 42

An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action would the nurse take?

a. Turn and reposition the patient.

b. Administer prescribed morphine.

c. Clamp the chest tube in two places.

d. Assist the patient with incentive spirometry.

Answer 42

b. Administer prescribed morphine.

Rationale: Treat the pain. The patient is unlikely to take deep breaths or cough or tolerate repositioning until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.

Question 43

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. Which assessment finding is of most concern?

a. A large air leak in the water-seal chamber

b. Report of pain with each deep inspiration

c. 400 mL of blood in the collection chamber

d. Subcutaneous emphysema at the insertion site

Answer 43

c. 400 mL of blood in the collection chamber

Rationale: The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain would be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema would be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.

Question 44

The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient?

a. Emergency pericardiocentesis

b. Stabilization of the chest wall

c. Bronchodilator administration

d. Chest tube connected to suction

Answer 44

d. Chest tube connected to suction

Rationale: The patient‘s history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient‘s clinical manifestations are not consistent with these problems.

Question 45

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which patient statement indicates that teaching has been effective?

a. “I am going to buy a rib binder to wear during the day.”

b. “I can take shallow breaths to prevent my chest from hurting.”

c. “I should plan on taking the pain pills only at bedtime so I can sleep.”

d. “I will use the incentive spirometer every hour or two during the day.”

Answer 45

d. “I will use the incentive spirometer every hour or two during the day.”

Rationale: Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis.

Question 46

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? (SATA)

a. tachypnea
b. deviation of the trachea
c. bradycardia
d. decreased use of accessory muscles
e. pleuritic pain

Answer 46

a. tachypnea
b. deviation of the trachea
e. pleuritic pain

Question 47

A nurse is assisting the provider to care for a patient who has developed a spontaneous pneumothorax. Which of the following actions should the nurse perform first?

a. assess the client’s pain
b. obtain a large-bore IV needle for decompression
c. administer lorazepam
d. prepare for chest tube insertion

Answer 47

b. obtain a large-bore IV needle for decompression

Question 48

A nurse is reviewing discharge instructions for a client who has COPD and experienced a pneumothorax. Which of the following statements should the nurse include?

A. “Notify your provider if you experience weakness.”

B. “You should be able to return to work in 1 week.”

C. “You need to wear a mask when in crowded areas.”

D. “Notify your provider if you experience a productive cough.”

Answer 48

D. “Notify your provider if you experience a productive cough.”