A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:
A. Diminished or absent breath sounds on the affected side. B. Paradoxical chest wall movement with respirations. C. Tracheal deviation to the unaffected side. D. Muffled or distant heart sounds.
Diminished or absent breath sounds on the affected side.-rationale: in the case of a pneumothorax, auscultating for breath sounds will reveal absent or diminished breath sounds on the affected side. paradoxical chest wall movements occur in flail chest conditions. tracheal deviation occurs in a tension pneumothorax. muffled or distant heart sounds occur in cardiac tamponade.client needs category: physiological integrityclient needs subcategory: basic care and comfortcognitive level: analysisreference: smeltzer, s.c., and bare, b. brunner & suddarths textbook of medical surgical-nursing, 11th ed. philadelphia: lippincott williams & wilkins, 2008, p. 696.