During a central IV line insertion at the bedside, a client reports shortness of breath and becomes tachypneic. Which finding should a nurse suspect indicates the client developed a pneumothorax?

Choice A rationale
While the application of anti-embolism stockings can be beneficial in preventing deep vein thrombosis in postoperative patients, it is not the most prioritized nursing intervention in the immediate postoperative period for a patient who has undergone a left pneumonectomy. The immediate postoperative period after a pneumonectomy is critical for monitoring and managing potential complications such as respiratory distress, hemorrhage, and bronchopleural fistula.
Choice B rationale
The use of the incentive spirometer is an important nursing intervention for postoperative patients to promote lung expansion and prevent atelectasis. However, in the immediate postoperative period following a pneumonectomy, the priority is to monitor for complications and ensure the stability of the patient.
Choice C rationale
Assessment of the chest tube and pleur-evac is the most prioritized nursing intervention in the immediate postoperative period for a patient who has undergone a left pneumonectomy. After a pneumonectomy, a chest tube is placed to drain air, blood, and fluid from the pleural space to allow the remaining lung to re-expand. It is crucial to monitor the chest tube system for proper functioning and to assess for complications such as excessive bleeding, infection, or pneumothorax.
Choice D rationale
Repositioning the patient in bed is a standard nursing intervention in postoperative care to enhance comfort, promote lung expansion, and prevent complications such as pressure ulcers and deep vein thrombosis. However, it is not the most prioritized intervention in the immediate postoperative period following a pneumonectomy, where monitoring for respiratory complications and ensuring the stability of the patient are paramount.

Choice A rationale
Muffled heart sounds are not a typical sign of pneumothorax. They are more commonly associated with conditions such as pericardial effusion or cardiac tamponade.
Choice B rationale
Sudden hemoptysis, or coughing up blood, is not a typical sign of pneumothorax. It is more commonly associated with conditions such as pulmonary embolism or lung cancer.
Choice C rationale
Absent breath sounds on the affected side is a typical sign of pneumothorax. When air enters the pleural space and causes the lung to collapse, breath sounds may be absent or significantly decreased on the affected side.
Choice D rationale
A declining respiratory rate is not a typical sign of pneumothorax. In fact, a rapid respiratory rate (tachypnea) is more commonly observed in pneumothorax due to the body’s attempt to compensate for the decreased lung capacity.