A nurse is caring for a client who underwent thoracic surgery. Which among the following should the nurse perform to assess for manifestations of tension pneumothorax? 

Assess for lateral or medial PMI shift
Check for laryngeal and tracheal deviation to unaffected side
Monitor blood pressure, pulse rate and respirations
Monitor for progressive cyanosis, extreme restlessness and agitation and severe dyspnea

Explanation

•Tension pneumothorax develops when air is trapped in the pleural space during inspiration and cannot escape during expiration. The intrapleural pressure becomes greater than the lung tissue pressure, resulting in compression of the lung and surrounding structures. The clinical manifestations include Point of Maximal Impulse (PMI) shift; tracheal deviation toward the unaffected side; progressive cyanosis, restlessness, anxiety, dyspnea; sudden sharp pain on the affected side with chest movement, breathing, or coughing; asymmetrical chest expansion; and diminished or absent breath sounds on the affected side.

•Evidence of labored breathing and hemodynamic compromise (eg, tachycardia, hypotension) suggests a possible tension pneumothorax.

•Crackles is one of the manifestations for acute pulmonary edema. This is monitored in clients who may have circulatory overload resulting from the reduced size of the pulmonary vascular bed due to surgical removal of pulmonary tissue and delayed reexpansion of the affected lung.

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