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Difficulty: MediumPhysiological Adaptation

An intensive care nurse is caring for a client who is receiving positive pressure mechanical ventilation. The ventilator's high-pressure alarm suddenly sounds, and the client's oxygen saturation drops to 84%. Assessment reveals absent breath sounds over the right lung field, a blood pressure of 82/40 mm Hg, and the trachea deviated toward the left. Which of the following interventions should the nurse anticipate performing immediately?

  1. Assisting the provider with an emergent needle thoracostomyAnswer
  2. B
    Performing deep in-line endotracheal suctioning
  3. C
    Initiating a rapid infusion of intravenous normal saline
  4. D
    Drawing an arterial blood gas sample to assess hypoxia

Answer

The nurse should immediately assist the provider with an emergent needle thoracostomy.
The client is exhibiting classic signs of a tension pneumothorax (absent breath sounds on one side, tracheal deviation, and hypotension), which is a known complication of positive pressure ventilation (barotrauma). The increased intrathoracic pressure compresses the heart and great vessels, causing obstructive shock. The immediate life-saving intervention is needle thoracostomy (decompression) to release the trapped air, followed by chest tube insertion.

Step-by-Step Solution

1
Analyze the assessment findings.
Absent breath sounds on the right, hypotension, and left-sided tracheal deviation in a ventilated client indicate a right-sided tension pneumothorax.
Positive pressure ventilation can cause barotrauma, leading to trapped air in the pleural space.
2
Identify the pathophysiological priority.
The trapped air increases intrathoracic pressure, collapsing the lung and compressing the heart and great vessels (obstructive shock).
This compression drastically reduces venous return and cardiac output, causing severe hypotension and hypoxia.
3
Determine the immediate life-saving intervention.
Needle thoracostomy must be performed to quickly release the trapped air.
Relieving the pressure restores venous return and allows the unaffected lung to expand, stabilizing the client.

Key Concept

Tension pneumothorax requires immediate clinical recognition and decompression; it is a form of obstructive shock where delayed intervention is fatal.
Estimated Time:1m 0s
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Topics

Physiological Adaptation

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