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Question

Difficulty: MediumReduction of Risk Potential

A nurse is caring for a client who has a right-sided chest tube for the treatment of a spontaneous pneumothorax. The client suddenly exhibits severe dyspnea, tachycardia, and extreme restlessness. The nurse observes that the trachea is deviated to the left and tidaling in the water-seal chamber has abruptly stopped. A stat arterial blood gas (ABG) reveals a pH of 7.247.24, a PaCO2\text{PaCO}_2 of 62 mm Hg62\text{ mm Hg}, and a PaO2\text{PaO}_2 of 52 mm Hg52\text{ mm Hg}. Which action should the nurse take first to reduce the client's risk of physiological deterioration?

  1. A
    Request a prescription for intravenous sodium bicarbonate to correct the acidosis.
  2. Inspect the entire length of the chest drainage tubing for kinks or dependent loops.Answer
  3. C
    Lower the head of the bed to a flat, supine position to stabilize the mediastinal shift.
  4. D
    Perform a comprehensive auscultation of all lung fields to confirm absent breath sounds.

Answer

Inspect the entire length of the chest drainage tubing for kinks or dependent loops.
The client is exhibiting classic signs of a tension pneumothorax: tracheal deviation away from the affected side, severe hypoxemia, and uncompensated respiratory acidosis. The abrupt cessation of tidaling in the water-seal chamber strongly suggests a mechanical occlusion in the chest tube system. The nurse's immediate priority is to examine the tubing for kinks, dependent loops, or closed clamps. Relieving this mechanical obstruction will rapidly decompress the pleural space, reverse the mediastinal shift, and prevent cardiopulmonary collapse.

Step-by-Step Solution

1
Analyze the physical findings and diagnostic data.
The combination of tracheal deviation away from the affected side, absent tidaling, and severe respiratory acidosis indicates a tension pneumothorax.
Air is trapped in the pleural space because the chest tube is occluded, causing intrathoracic pressure to build and compress the mediastinum.
2
Identify the immediate priority to reduce the risk of cardiopulmonary arrest.
The nurse must find and eliminate the cause of the obstruction in the chest drainage system.
Restoring the patency of the chest tube will allow the trapped air to escape, rapidly resolving the tension pneumothorax and improving the client's ability to ventilate.

Key Concept

Management of Chest Tube Complications and Tension Pneumothorax
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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