# A nurse is caring for a postoperative patient who develops severe respiratory distress with decreased oxygen saturation, increased peak inspiratory pressures, and absent breath sounds on the right side while on mechanical ventilation. What is the most appropriate immediate nursing action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=542616  
> language: ko  
> subject: Critical Care

## 문제

A nurse is caring for a postoperative patient who develops severe respiratory distress with decreased oxygen saturation, increased peak inspiratory pressures, and absent breath sounds on the right side while on mechanical ventilation. What is the most appropriate immediate nursing action?

## 보기

1. Increase the FiO2 to 100% and notify the respiratory therapist
2. Prepare for immediate needle decompression and notify the physician stat **✔ 정답**
3. Suction the endotracheal tube and reposition the patient
4. Administer a bronchodilator and increase PEEP settings

**정답: 2**

## 해설

Severe respiratory distress with decreased O2 saturation, increased PIP, and absent breath sounds on one side indicates tension pneumothorax, requiring immediate needle decompression. Other options (increasing FiO2, suctioning, bronchodilators) do not address the life-threatening pressure buildup.

## 심화 해설

Clinical Judgment
This situation describes a life-threatening emergency called Tension Pneumothorax occurring in a patient on mechanical ventilation. The key clues are severe respiratory distress, decreased oxygen saturation, increased peak inspiratory pressure, and absent breath sounds on one side (right). Tension pneumothorax is a condition where pressure within the pleural space continuously increases, compressing the lung and shifting the heart and great vessels; without immediate decompression, it rapidly progresses to cardiovascular collapse and cardiac arrest. The positive pressure from mechanical ventilation further worsens this condition. Therefore, the most appropriate immediate nursing action is to prepare for Needle Decompression while immediately notifying the physician. This is an emergency procedure where a large-bore needle is inserted into the second intercostal space at the midclavicular line on the affected side to rapidly reduce pressure.

Memory Tip: Remember the emergency response for tension pneumothorax as "**D**ecompress **S**tat!". When symptoms appear suddenly, breath sounds are absent on one side, and especially during mechanical ventilation, you must think of immediate decompression.

KR vs US: In Korea, needle decompression may be within the scope of a physician or emergency medicine specialist, but in US NGN scenarios, the nurse's proactive role in recognizing the emergency, immediately preparing the necessary equipment, and reporting to the physician is emphasized. The action of 'Prepare' is key.

## 임상 시나리오

Clinical Practice Guide
When tension pneumothorax is suspected:
1. Immediately notify the physician (Stat Notification).
2. Prepare a needle decompression kit (14-16G needle, at least 5 cm in length).
3. Prepare the insertion site (second intercostal space at the midclavicular line on the affected side) by cleaning it with an alcohol swab.
4. Keep the patient in a semi-upright position and maximize oxygen delivery if possible (FiO2 100%).
5. After needle decompression, definitive treatment with chest tube insertion typically follows.
Caution: In SATA (Select All That Apply) questions asking about "immediate interventions," 'preparing for needle decompression' and 'immediately notifying the physician' are a critical pair of actions that should be selected together. Simply 'calling a respiratory therapist' or 'changing ventilator settings' are delaying actions that can worsen the risk.

## 핵심 개념

- **Tension Pneumothorax** — Tension pneumothorax. A condition where air enters the pleural cavity but cannot escape due to a 'one-way valve' mechanism, causing pressure to continuously increase. It compresses the lung and shifts the mediastinum toward the unaffected side, obstructing venous blood return to the heart, and is a life-threatening emergency.
- **Needle Decompression** — Needle decompression. An emergency treatment for tension pneumothorax, where a large-bore needle (usually 14G or 16G) is inserted into the second intercostal space at the midclavicular line on the affected side to release excessive air pressure from the pleural cavity to the outside.
- **Mechanical Ventilation** — Mechanical ventilation. A treatment that assists or replaces a patient's breathing using a ventilator. Positive pressure ventilation can be a risk factor for pneumothorax, such as tension pneumothorax.
- **Peak Inspiratory Pressure** — Peak inspiratory pressure. The maximum pressure applied to the airway during mechanical ventilation. In tension pneumothorax, increased pleural cavity pressure makes lung expansion difficult, so the PIP required to deliver the same volume of air rises sharply.
- **Chest Tube Thoracostomy** — Chest tube insertion. This is a definitive treatment following needle decompression, where a chest tube is inserted into the pleural cavity through the intercostal space to continuously drain air or fluid and promote lung re-expansion.

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