The nurse is assisting with a subclavian vein central line insertion when the patient's oxygen saturation rapidly drops
He complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include:
A) Diminished or absent breath sounds on the affected side
B) Paradoxical chest wall movement with respirations
C) Tracheal deviation to the unaffected side
D) Muffled or distant heart sounds
Ans: A
Feedback: In the case of a pneumothorax, auscultating the breath sounds reveals absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in pericardial tamponade.
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