A client with a gunshot wound to the chest is suspected as having a tension pneumothorax. What should the nurse expect to assess for this health problem?
1. High blood pressure
2. Audible sucking sounds on inspiration
3. Wheezes in all lung fields
4. Deviated trachea
Answer: 4
1. High blood pressure is not associated with a tension pneumothorax.
2. Audible sucking sounds are not associated with a tension pneumothorax.
3. Wheezing is not associated with a tension pneumothorax.
4. As air enters the pleural space, it is unable to escape, and accumulates, causing collapse of the lung on the affected side and shifting of the heart, trachea, and esophagus to the unaffected side.
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