# The nurse reviews the record after central venous catheter placement. Which findings require immediate follow-up for possible tension pneumothorax? Highlight the findings that support rapid obstructive deterioration. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=494428&lang=en > language: en > subject: Medical Emergencies > category: PA ## Question The nurse reviews the record after central venous catheter placement. Which findings require immediate follow-up for possible tension pneumothorax? Highlight the findings that support rapid obstructive deterioration. Nurses' Notes 1015: A right internal jugular central venous catheter is placed without immediate difficulty. At 1030, new severe shortness of breath begins. The temperature is 37.1 °C. The nurse documents that the temperature remains unchanged from the preprocedure value. Before the procedure, chest expansion was symmetric with clear breath sounds. At 1035, right-sided breath sounds are absent. The insertion dressing is dry and intact. The client reports mild tenderness limited to the catheter insertion site. At 1040, the respiratory rate increases from 18/min to 34/min. The nurse notes that the earlier respiratory rate was 18/min at rest. At 1042, blood pressure is 78/46 mm Hg; hypotension occurs with new tracheal deviation. The oxygen saturation had been 97% on 2 L/min before the change. The record confirms that oxygen saturation was stable before the procedure. The catheter lumens flush without resistance. The nurse documents that each lumen flushes and has a labeled cap. Emergency equipment is brought to the bedside. ## Explanation Follow up on sudden severe dyspnea, absent right breath sounds, and hypotension with tracheal deviation. This pattern can indicate tension pneumothorax and requires emergency treatment without waiting for routine imaging. ## In-depth explanation Quick answer The urgent pattern is sudden severe dyspnea, absent breath sounds on the right, and new hypotension with tracheal deviation. Together these findings support tension physiology after a central-line procedure. Why this is correct Air trapped under pressure can collapse the affected lung and shift mediastinal structures, reducing venous return and cardiac output. Progressive respiratory distress, unilateral absent breath sounds, oxygen decline, and shock findings require immediate action. In a rapidly deteriorating client, treatment is based on the clinical pattern rather than delayed for routine confirmation.[2] Easy analogy or mental picture Picture a one-way valve filling a sealed side of the chest like an expanding air cushion. The cushion compresses the lung and then pushes on the heart's filling pathway. This picture explains pressure, but the nurse still uses the whole assessment because no single sign is always present. Memory hook One silent side plus falling breathing and pressure means trapped chest pressure. NCLEX decision rule After a thoracic or central-line procedure, treat abrupt respiratory distress with unilateral breath-sound loss and hemodynamic decline as an emergency. Do not wait for every late sign or for routine imaging when the client is unstable. Why the other choices are wrong A normal temperature, dry insertion dressing, mild expected soreness, previously symmetric expansion, stable oxygenation, and a flushing catheter do not explain the new obstructive shock pattern. They are routine observations rather than the priority cues targeted here.References - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]Joint Trauma System: Wartime Thoracic Injury CPGU.S. Department of Defense ## Related questions - [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=en) - [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=en) - [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=en) - [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=en) - [A 68-year-old client is admitted to the emergency department with suspected sepsis from a …](https://mymerci.kr/pages/nclex_q.php?qn_id=363987&lang=en) - [A nurse is caring for an adult client in the emergency department who is suspected to have…](https://mymerci.kr/pages/nclex_q.php?qn_id=363993&lang=en) - [A nurse is teaching a 72-year-old client with chronic heart failure (reduced ejection frac…](https://mymerci.kr/pages/nclex_q.php?qn_id=366202&lang=en) - [A nurse is caring for an adult client admitted with diabetic ketoacidosis. 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