The nurse is caring for a client on mechanical ventilation with positive end expiratory pressure (PEEP). When assessing the client, which of the following findings would alert the nurse to the possibility of tension pneumothorax?
1. New onset of decreased breath sounds over the right lung
2. Blood pressure of 170/80
3. Pulse oximetry readings ranging from 94% to 96%
4. Crackles and wheezing heard in both lungs
New onset of decreased breath sounds over the right lung
Rationale: In a tension pneumothorax, air enters the pleural space with each breath but does not exit. Progressive accumulation of air in the pleural space leads to collapse of the lung on the affected side and hypoxia. As a result, the client would have decreasing breath sounds on the affected side rather than adventitious sounds (crackles and wheezes). As the pressure in the thorax increases, cardiac output declines and the client becomes hypotensive. A pulse oximetry reading of 94% demonstrates adequate oxygenation.
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