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

Assess for lateral or medial Point of Maximal Impulse (PMI) shift.
Check for tracheal deviation to unaffected side.
Monitor blood pressure, heart rate, and respirations.
Monitor for progressive cyanosis, extreme restlessness, agitation, and severe dyspnea.

Explanation

•Tension pneumothorax usually results from trauma (such as a stab wound) and 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, and 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 (for example, tachycardia, hypotension) suggest a possible tension pneumothorax.

•Crackles are a manifestation of acute pulmonary edema, seen with circulatory overload, resulting from delayed re-expansion of the affected lung after surgical treatment.

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