Question

The nurse is caring for a patient who is undergoing a subclavian vein central line insertion. During placement, the nurse notes the client's oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. Which of the following assessment findings would be indicative that a pneumothorax has developed?

A. Muffled heart sounds

B. Diminished or absent breath sounds

C. Rales and wheezing on auscultation

D. Abdominal distention

Answer 1

Answer is diminished or absent breath sounds.

When the patient develops pneumothorax the breath sounds become diminished or absent. Pneumothorax is the condition in which air leaked into the thorax or surrounding of lungs. And while auscultation we cannot assess the breath sounds.

Muffled heart sounds are occurs when there is any barrier present between heart and chest wall. Abdominal distension may seen in any gastrointestinal disorder. Wheezing on auscultation is the sign of any fluid collection or pus collection in the lung.