Pneumothorax vs Tension Pneumo
A tall, thin 21-year-old presents with sudden unilateral chest pain and mild dyspnea. Vitals are stable. Breath sounds decreased on the right side.
What type of pneumothorax is most likely?
Bonus Question: Why are tall, thin young males at higher risk?
Answer: Primary spontaneous pneumothorax.
Bonus Answer: Rupture of apical blebs due to increased negative intrapleural pressure at the lung apex.
You observe intermittent bubbling in the water seal chamber of a chest tube system. What does this indicate?
⭐ Bonus Question:
What is “tidaling,” and what does it reflect physiologically?
Intermittent bubbling in the water seal chamber is expected early after pneumothorax and indicates air is leaving the pleural space.
⭐ Bonus Answer:
Tidaling is the rise and fall of fluid in the water seal chamber with respiration. It reflects changes in intrathoracic pressure during inspiration and expiration.
A patient with blunt chest trauma develops increasing dyspnea and crackles 24 hours later. What complication should you suspect?
⭐ Bonus Question:
Why might this complication not be immediately visible on initial chest X-ray?
Pulmonary contusion.
⭐ Bonus Answer:
Pulmonary contusions can worsen over 24–48 hours as inflammation and capillary leakage increase, so early imaging may not show full injury.
Immediately after chest tube insertion, what are your TOP 3 priority assessments?
⭐ Bonus Question:
Which assessment finding would require immediate provider notification?
Respiratory status (RR, effort, breath sounds, SpO₂)
Chest tube system (tidaling, bubbling, suction level)
Drainage amount and color
⭐ Bonus Answer:
Sudden large amount of bright red blood (>1500 mL immediately or >200 mL/hr), worsening respiratory distress, or signs of tension pneumothorax.
A patient with pneumothorax is on 2 L NC with SpO₂ 90%. Per class guidance, how should you titrate oxygen?
⭐ Bonus Question:
Why is pain NOT your first priority even if the patient rates pain 10/10?
Increase oxygen in increments (e.g., 2 L at a time) and reassess until SpO₂ ≥ 94%.
⭐ Bonus Answer:
ABCs. Oxygenation is life-threatening; pain is not immediately fatal.
A patient with chest trauma becomes hypotensive, tachycardic, and develops tracheal deviation.
What is occurring?
Bonus Question: Why does hypotension occur in this case?
Answer:
Tension pneumothorax.
Bonus Answer:
Increased intrathoracic pressure compresses the vena cava → decreased venous return → decreased cardiac output.
You observe continuous bubbling in the water seal chamber. What does this most likely indicate?
⭐ Bonus Question:
What is your first nursing action?
Continuous bubbling indicates an air leak in the system.
⭐ Bonus Answer:
First, assess the system from the patient toward the drainage unit to identify the source of the leak. Briefly clamp near the patient to determine if the leak is from the patient or tubing (per facility protocol).
A patient with multiple rib fractures has paradoxical chest wall movement during breathing. What condition is this?
⭐ Bonus Question:
Why is this condition dangerous from a gas exchange standpoint?
Flail chest.
⭐ Bonus Answer:
Paradoxical movement impairs ventilation, decreases tidal volume, and increases risk of hypoxia and respiratory failure.
How do you know a patient with a chest tube is stable enough for transfer to a step-down/intermediate unit?
⭐ Bonus Question:
What complication are you still anticipating even if stable?
Stable vital signs, improved oxygenation, controlled drainage, no air leak, no signs of respiratory distress.
⭐ Bonus Answer:
Recurrent pneumothorax, infection, tube obstruction, bleeding.
A chest tube drains 250 mL of bright red blood in the first hour after insertion. The next hour it drains 220 mL. What does this suggest?
⭐ Bonus Question:
What is your priority intervention?
Ongoing active bleeding — exceeds 200 mL/hr threshold.
⭐ Bonus Answer:
Notify provider immediately and prepare for possible surgical intervention (risk of hypovolemic shock).
Question:
What is the immediate life-saving intervention for tension pneumothorax?
Bonus Question:
Where is the needle typically inserted?
Answer:
Needle decompression (needle thoracostomy), followed by chest tube placement.
Bonus Answer:
2nd intercostal space, midclavicular line (or 4th/5th ICS anterior axillary line depending on protocol).
Sudden cessation of tidaling in a patient with pneumothorax and a chest tube could indicate what?
⭐ Bonus Question:
How would you differentiate between lung re-expansion and tube obstruction?
It may indicate lung re-expansion OR obstruction of the chest tube.
⭐ Bonus Answer:
Assess the patient: improved breath sounds and stable vitals suggest re-expansion. Signs of distress, diminished sounds, or tubing kinks/clots suggest obstruction.
A trauma patient develops hypotension, muffled heart sounds, and jugular venous distention. What complication is occurring?
⭐ Bonus Question:
What is the pathophysiologic mechanism causing hypotension in this condition?
Cardiac tamponade.
⭐ Bonus Answer:
Fluid accumulation in the pericardial sac compresses the heart, preventing adequate ventricular filling → decreased cardiac output → hypotension.
A patient with a chest tube for pneumothorax suddenly reports sharp chest pain and “can’t catch my breath.” SpO₂ drops from 96% → 88%. On the drainage system, tidaling stops and there is new continuous bubbling. What is the most likely problem?
⭐ Bonus Question:
What are your first 2 nursing actions (in order) before calling the provider?
Most likely a new air leak and/or loss of the water seal (e.g., system disconnection, loose connections, or tubing issue) causing recurrent pneumothorax/worsening air entry into pleural space.
⭐ Bonus Answer:
Assess the patient first (ABCs): increase oxygen, rapid respiratory assessment (work of breathing, breath sounds).
Immediately troubleshoot the system: check all connections/tubing for disconnection/kinks; ensure water seal is intact (and if disconnected, place tube end in sterile water to re-establish seal per protocol)
You have two chest trauma patients:
Patient A: Stable vitals, new continuous bubbling in water seal.
Patient B: BP 82/40, HR 132, absent breath sounds on left.
Who do you see first?
⭐ Bonus Question:
What is the likely diagnosis for Patient B?
Patient B.
⭐ Bonus Answer:
Tension pneumothorax with obstructive shock.
List 3 assessment findings that distinguish tension pneumothorax from a simple pneumothorax at the bedside.
Bonus Question:
Why is tracheal deviation a late sign?
Answer: Hypotension, Tracheal deviation, JVD, Severe respiratory distress, Tachycardia
Bonus Answer:
It occurs only after significant pressure builds in the pleural space and shifts mediastinal structures.
How much blood drainage from a chest tube suggests a hemothorax requiring immediate provider notification?
⭐ Bonus Question:
Why is rapid blood loss through a chest tube dangerous?
More than 1500 mL immediately after insertion OR greater than 200 mL/hr for 2–3 consecutive hours.
⭐ Bonus Answer:
Rapid blood loss can cause hypovolemic shock and indicates ongoing hemorrhage requiring surgical intervention.
A patient with rib fractures is refusing to cough or deep breathe due to pain. What major complication are they at risk for?
⭐ Bonus Question:
What nursing intervention directly reduces this risk?
Atelectasis and pneumonia.
⭐ Bonus Answer:
Aggressive pain control (e.g., PCA, nerve blocks) combined with incentive spirometry and TCDB (turn, cough, deep breathe).
A patient with a chest tube suddenly becomes dyspneic, and the tubing appears kinked under the bed. What is your FIRST action?
⭐ Bonus Question:
Why is dependent looping of tubing dangerous?
Immediately straighten the tubing and ensure it is not obstructed.
⭐ Bonus Answer:
Dependent loops can trap fluid, obstruct drainage, and increase intrathoracic pressure.
A 90 kg trauma patient requires a heparin bolus of 60 units/kg. The vial concentration is 5,000 units/mL.
What is the bolus dose in units?
How many mL will you draw up?
⭐ Bonus Question:
Why must you check platelets before and during therapy?
60 × 90 = 5,400 units.
5,400 ÷ 5,000 = 1.08 mL.
⭐ Bonus Answer:
Risk of Heparin-Induced Thrombocytopenia (HIT) → paradoxical clotting + bleeding risk.
A patient with a newly inserted chest tube suddenly becomes restless, hypotensive, and their trachea shifts away from the affected side. What is your FIRST nursing action?
Bonus Question:
Why is waiting for imaging dangerous?
Answer:
Call rapid response / notify provider immediately while preparing for emergent decompression.
Bonus Answer:
Tension pneumothorax is a clinical diagnosis — delayed intervention can lead to obstructive shock and cardiac arrest.
A chest tube becomes accidentally disconnected from the drainage system. What is your FIRST action?
⭐ Bonus Question:
Why should the chest tube never be clamped routinely?
Place the end of the chest tube in sterile water to re-establish a water seal until a new system is connected.
⭐ Bonus Answer:
Clamping can cause air to accumulate in the pleural space and potentially create a tension pneumothorax.
A trauma patient becomes suddenly hypotensive with absent breath sounds on one side and distended neck veins. You suspect tension pneumothorax. What is your immediate priority under ABCs?
⭐ Bonus Question:
Why is oxygen alone insufficient in this scenario?
Airway/Breathing — prepare for immediate needle decompression.
⭐ Bonus Answer:
The problem is mechanical pressure, not just oxygen deficiency. Oxygen will not relieve the intrathoracic pressure compressing the heart and lungs.
A chest tube accidentally comes out of the patient. What is your FIRST nursing action?
⭐ Bonus Question:
Why should you tape the dressing on only three sides?
Apply an occlusive sterile dressing immediately.
⭐ Bonus Answer:
Taping three sides creates a flutter valve effect — allows air to escape but prevents air from re-entering, reducing risk of tension pneumothorax.
A patient with rib fractures and pulmonary contusion suddenly becomes increasingly confused, tachypneic (RR 34), SpO₂ 86% on 4 L NC, and has crackles bilaterally.
ABG: pH 7.30, PaCO₂ 52, PaO₂ 60.
What complication is developing?
⭐ Bonus Question:
What is your FIRST intervention?
Acute respiratory failure (likely progressing toward ARDS).
⭐ Bonus Answer:
Escalate oxygen support immediately (NRB or prepare for intubation) and notify provider — airway/breathing first.