The nurse discovers that the client suddenly has become short of breath. Which of the following assessment findings would increase the nurse's suspicion of a spontaneous pneumothorax of the left lung? Standard Text: Select all that apply

Question

1. Diminished breath sounds in the bases bilaterally, with rhonchi in the left lower lobe
2. Trachea is at midline.
3. Subcutaneous emphysema palpable on the left side of the chest
4. Absent breath sounds on the left side of the chest
5. Tachycardia and tachypnea

Answer 1

3,4,5
Rationale: When the lung deflates due to a pneumothorax, the nurse will hear no breath sounds over the involved site. If air leaks from the lungs into the subcutaneous space, a crackling sensation will be felt—called subcutaneous emphysema—usually in the upper chest on the involved side. Heart rate can increase or decrease, respiratory rate increases, and the client reports suddenly feeling short of breath. A large pneumothorax can cause the trachea to shift to the side of the collapse, as chest organs suddenly have room to shift toward the empty space left by the pneumothorax. Breath sounds are not diminished, they are absent, as air is no longer entering the lobe or lobes of the lungs that are no longer functioning.