# A client is on day 2 after placement of a right chest tube for a spontaneous pneumothorax. While coughing, the client pulls the tube completely out; the tip is intact. Over the next 2 minutes the client becomes anxious. Respiratory rate is 28/min, heart rate 108/min, blood pressure 128/76 mm Hg, and oxygen saturation 88% on room air (95% one hour ago). Breath sounds are diminished on the right. The trachea is midline and neck veins are flat. A hissing sound comes from the insertion site, and there is a small amount of serous drainage without active bleeding. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617419&lang=en  
> language: en  
> subject: Postsurgical Complications  
> category: ROR

## Question

A client is on day 2 after placement of a right chest tube for a spontaneous pneumothorax. While coughing, the client pulls the tube completely out; the tip is intact. Over the next 2 minutes the client becomes anxious. Respiratory rate is 28/min, heart rate 108/min, blood pressure 128/76 mm Hg, and oxygen saturation 88% on room air (95% one hour ago). Breath sounds are diminished on the right. The trachea is midline and neck veins are flat. A hissing sound comes from the insertion site, and there is a small amount of serous drainage without active bleeding. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Recurrent simple pneumothorax
Tension pneumothorax on the right
Hemothorax from the tube tract
Atelectasis from splinting

Actions to take

Select 2
Prepare for immediate needle decompression
Obtain a stat chest x-ray before covering the site
Apply a sterile occlusive dressing to the site
Coach the client in incentive spirometry
Give oxygen and notify the provider now

Parameters to monitor

Select 2
Hemoglobin level
Oxygen saturation
Temperature at the insertion site
Breath sounds on the right
Incentive spirometer volume

## Explanation

Air hissing from an open insertion site, with new hypoxemia and diminished right breath sounds, indicates air re-entering the pleural space. The nurse covers the site with a sterile occlusive dressing and gives oxygen while notifying the provider. A midline trachea, flat neck veins, and stable blood pressure mean tension physiology has not developed, so needle decompression is not the current action.

## In-depth explanation

Quick answer
Recurrent pneumothorax after the chest tube came out. Cover the site with a sterile occlusive dressing, give oxygen, and notify the provider. Monitor oxygen saturation and right-sided breath sounds.

Why this is correct
The open tract lets air enter the pleural space with each breath, so the lung collapses again: saturation fell from 95% to 88% and right breath sounds are diminished. The midline trachea, flat neck veins, and blood pressure of 128/76 show that tension has not developed. Sealing the site stops more air from entering, oxygen treats hypoxemia, and the provider decides on reinsertion. Saturation and breath sounds show whether the lung stays expanded or collapses further.

Easy analogy or mental picture
The chest tube hole is an open window in a sealed room: shut the window first, then call for the repair crew.

Memory hook
Tube out: seal it, oxygenate, call. Needle only if trachea shifts and BP drops.

NCLEX decision rule
Choose the intervention that matches the current severity. Escalate to decompression only when data show tension physiology (tracheal shift, hypotension, distended neck veins).

Why the other choices are wrong
Needle decompression is correct for tension pneumothorax, but the trachea is midline and the client is not hypotensive. Getting an x-ray before covering the site delays the step that stops air entry. Incentive spirometry and spirometer volume fit atelectasis, but a hiss from an open site signals an air leak, not splinting. Hemoglobin tracks hemothorax, yet there is no active bleeding, and site temperature addresses infection, not the immediate air leak.

References
1MedlinePlus — Collapsed Lung (Pneumothorax)Signs of pneumothorax and the role of chest tube drainage

## Clinical scenario

Scenario
A right chest tube is pulled out during coughing; the client becomes hypoxemic with diminished right breath sounds and an air hiss from the site, while the trachea stays midline and blood pressure is stable.

## Key concepts

- **Occlusive dressing** — An airtight dressing that prevents air from entering the pleural space through an open chest wound.
- **Tension pneumothorax** — Trapped pleural air under pressure that shifts the mediastinum and impairs venous return, causing hypotension.
- **Tracheal deviation** — Displacement of the trachea away from the affected side, a late sign of tension pneumothorax.

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