NCLEX-RN

Category - Reduction of Risk

A nurse is preparing to insert a CVP line on Hany, a 44-year-old female client with cancer. After the physician inserted the CVP line, the nurse should watch out for specific signs of pneumothorax. Which of the following findings indicates that the client has developed pneumothorax?
  1. Sudden onset of shortness of breath
  2. Uneven chest movement
  3. Tachycardia, hypotension
  4. Sudden onset of cough with frothy sputum
Explanation
Answer: D - An onset of cough with frothy sputum indicates pneumothorax. After the procedure, the nurse must watch out for signs of pneumothorax caused by possible puncture of the pleural cavity. Shortness of breath, paradoxical chest movement and chest pain should be reported immediately. Be alert for such signs of air embolism as sudden onset of pallor, cyanosis, dyspnea, coughing, and tachycardia, progressing to syncope and shock. If any of these signs occur, place the client on their left side in Trendelenburg's position and notify the physician.
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