# A nurse is caring for a patient who sustained multiple rib fractures and a pneumothorax in a motor vehicle accident. The patient has a chest tube inserted and connected to a water-seal drainage system. Which nursing action should be the highest priority?

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## 문제

A nurse is caring for a patient who sustained multiple rib fractures and a pneumothorax in a motor vehicle accident. The patient has a chest tube inserted and connected to a water-seal drainage system. Which nursing action should be the highest priority?

## 보기

1. Administer prescribed pain medication to improve patient comfort
2. Encourage deep breathing and coughing exercises to prevent pneumonia
3. Monitor chest tube drainage output and document findings
4. Assess for signs of tension pneumothorax and notify the physician immediately **✔ 정답**

**정답: 4**

## 해설

In chest trauma with pneumothorax, assessing for tension pneumothorax is the highest priority due to its life-threatening nature. Other options are important but secondary to immediate recognition of this emergency.

## 심화 해설

Understanding the Priority: Airway and Breathing Over Comfort

In a patient with multiple rib fractures and a known pneumothorax managed with a chest tube, the clinical situation can change rapidly. The chest tube and water-seal drainage system are designed to remove air from the pleural space and restore negative pressure, allowing the lung to re-expand. However, if the chest tube becomes kinked, occluded, or is simply overwhelmed by a continuous air leak, air can re-accumulate in the pleural space. Because the injury involved multiple ribs, there is a high risk of a continuing air leak from the lung parenchyma, which the existing chest tube may not fully evacuate. This can lead to the development of a tension pneumothorax, a life-threatening emergency where accumulating air shifts the mediastinum, compresses the great vessels, and severely impairs cardiac output and ventilation.

The Guidelines for Essential Trauma Care emphasize that the organization of trauma care must prioritize the immediate recognition and management of life-threatening conditions to lower mortality [1]. In this context, the highest priority nursing action is not a routine task, but a focused clinical assessment to rule out an imminent threat to the patient's airway, breathing, and circulation. While administering pain medication (Option 1) and encouraging pulmonary hygiene (Option 2) are important components of care for rib fractures to prevent secondary complications like pneumonia, they are secondary to ensuring the patient’s immediate physiological stability. Monitoring chest tube output (Option 3) is a necessary ongoing assessment, but the act of documenting findings does not take precedence over actively assessing for and responding to a critical change in the patient's condition. The nurse must first ensure the current intervention (the chest tube) is effectively doing its job and that a more severe, rapidly fatal complication is not developing.

Clinical Recognition of Tension Pneumothorax

The assessment for tension pneumothorax involves a rapid evaluation for signs of progressive respiratory distress and hemodynamic instability. The nurse should look for:

- Severe tachypnea and dyspnea

- Tracheal deviation away from the affected side (a late sign)

- Absent or severely diminished breath sounds on the affected side

- Distended neck veins due to increased intrathoracic pressure

- Tachycardia and hypotension, indicating obstructive shock

- Cyanosis or hypoxemia, as reported in a case of post-procedural air leak where a patient developed acute respiratory distress and a drop in oxygen saturation .

If these signs are present, it indicates that the mediastinal shift is compromising venous return and ventilation. This is a clinical diagnosis that must be acted upon immediately by notifying the physician and preparing for emergency decompression, as it can lead to cardiac arrest if untreated. The decision-making process for pneumothorax management, including the need for urgent intervention, relies on this type of rapid clinical and radiographic assessment . The nurse's priority is to perform this focused assessment to identify a tension pneumothorax and escalate care without delay, as this directly addresses the most immediate threat to the patient's survival.References (research sources)

- [1]Guidelines for Essential Trauma Care: Second Edition (2026).GuidelineMock C, Hardcastle TC, Gaarder C, Gupta A, Gyedu A, Joshipura M, Steyn E, Essential Trauma Care revision author group. (2026) · DOI: 10.1002/wjs.70321

## 임상 시나리오

Tension Pneumothorax: Priority AssessmentRecognizing a Life-Threatening Complication in Chest Trauma
In a patient with rib fractures and a chest tube, the highest priority is assessing for tension pneumothorax. A functioning chest tube does not rule out a new or worsening air leak that can overwhelm the system, leading to mediastinal shift and cardiovascular collapse.

Key assessment findings include severe respiratory distress, tracheal deviation away from the affected side, distended neck veins, absent breath sounds, and hypotension. This is a clinical diagnosis that requires immediate notification of the physician and preparation for emergency decompression.

CautionNever clamp a chest tube to assess for an air leak without a specific order, as this can rapidly convert a simple pneumothorax into a tension pneumothorax. Continuous bubbling in the water seal chamber indicates a persistent air leak requiring immediate evaluation.

## 핵심 개념

- **Tension Pneumothorax** — A life-threatening condition where air accumulates in the pleural space under pressure, causing lung collapse, mediastinal shift, and compromised cardiac output.
- **Water-Seal Drainage System** — A chest drainage system that uses a water seal to allow air and fluid to exit the pleural space while preventing atmospheric air from re-entering.
- **Mediastinal Shift** — The movement of the heart, trachea, and great vessels to one side of the chest, a classic sign of tension pneumothorax that obstructs venous return.

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