Which nursing assessment would alert a nurse to the development of a mediastinal shift, in a client with tension pneumothorax?
A) Fluctuation of the fluid in the water-seal chamber
B) Shift of rib cage toward affected side
C) Sucking sound heard on inspiration and expiration
D) Shift of trachea, esophagus, heart, and great vessels
D
Feedback:
In a tension pneumothorax, the air is sucked into the pleural cavity and cannot escape. The air accumulates and pushes the trachea, esophagus, heart, and great vessels toward the unaffected side. Fluctuation of the fluid in the water-seal chamber is an expected finding. There may be a paradoxical movement of the ribs but not a shifting to the side. A sucking sound may be heard with a pneumothorax, but air moves in and cannot escape out.
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