6) A client has been admitted with chest trauma after a motor vehicle crash and hasundergone subsequent intubation. The nurse checks the client when thehighpressure alarm on the ventilator sounds and notes that the client has an absenceof breath sounds in the right upper lobe of the lung. The nurse immediately assessesfor other signs of which condition?(a) Right pneumothorax(b) Pulmonary embolism(c) Displaced endotracheal tube(d) Acute respiratory distress syndrome
Question
- A client has been admitted with chest trauma after a motor vehicle crash and hasundergone subsequent intubation. The nurse checks the client when thehighpressure alarm on the ventilator sounds and notes that the client has an absenceof breath sounds in the right upper lobe of the lung. The nurse immediately assessesfor other signs of which condition?(a) Right pneumothorax(b) Pulmonary embolism(c) Displaced endotracheal tube(d) Acute respiratory distress syndrome
Solution
The nurse should immediately assess for other signs of a right pneumothorax.
Here's why:
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The absence of breath sounds in the right upper lobe of the lung is a common sign of a pneumothorax, which is a collapsed lung. This can occur due to trauma, such as a motor vehicle crash.
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The high-pressure alarm on the ventilator can be triggered by increased pressure within the airways, which can occur if air is leaking into the space between the lung and chest wall (a pneumothorax).
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Other signs of a pneumothorax that the nurse should look for include sudden chest pain, shortness of breath, rapid heart rate, rapid breathing, and a decrease in blood pressure.
Therefore, the correct answer is (a) Right pneumothorax.
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