A nurse notices a patient's chest wall moving in during inspiration and out during expiration. What additional assessment must the nurse perform immediately?

Question

Quizplus · Accepted Answer

Chest wall moving in during inspiration and out during expiration is paradoxical chest wall movement. It can be caused by a tension pneumothorax, which increases intrathoracic pressure in the thorax, causing tracheal deviation and indicating mediastinal shift. Tension pneumothorax does not create bronchovesicular breath sounds in the lung periphery. Option C is performed when the patient has air in the subcutaneous tissue or pleural friction rub. Absent breath sounds may be found in pneumothorax, but if the patient has a tension pneumothorax, tracheal deviation is a more important sign.

A Nurse Notices a Patient's Chest Wall Moving in During