# Situation: A 24-year-old tall, thin man who smokes arrives with sudden right-sided chest pain and breathlessness. He has no known lung disease and no history of injury. A chest X-ray shows a large right pneumothorax, and a chest tube is planned. On day 3 the nurse finds him lying on a kinked section of the tubing, acutely breathless. Which finding BEST distinguishes a developing tension pneumothorax from a simple re-accumulation of air on the right?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630218  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 24-year-old tall, thin man who smokes arrives with sudden right-sided chest pain and breathlessness. He has no known lung disease and no history of injury. A chest X-ray shows a large right pneumothorax, and a chest tube is planned.

On day 3 the nurse finds him lying on a kinked section of the tubing, acutely breathless. Which finding BEST distinguishes a developing tension pneumothorax from a simple re-accumulation of air on the right?

## 보기

1. Absent breath sounds over the right chest
2. Hypotension with distended neck veins **✔ 정답**
3. Hyperresonance when the right chest is percussed
4. Sharp right-sided chest pain on inspiration

**정답: 2**

## 해설

Absent breath sounds, hyperresonance, and pleuritic pain occur in both simple and tension pneumothorax. What defines tension is rising pressure that shifts the mediastinum and impairs venous return, causing hypotension and distended neck veins; it needs immediate decompression.

## 심화 해설

The distinguishing finding
A kinked chest tube can trap air in the pleural space. Both a simple re-accumulation of air and a developing tension pneumothorax cause breathlessness, absent breath sounds, hyperresonance, and pleuritic pain on the affected side. What sets tension apart is its effect on the circulation: rising intrapleural pressure shifts the mediastinum and impairs venous return to the heart. Hypotension with distended neck veins shows tension physiology and calls for immediate decompression.

The mechanism of tension
In tension pneumothorax, air enters the pleural space but cannot leave, acting like a one-way valve. Pressure builds with each breath, compressing the lung and pushing the mediastinum toward the opposite side. The great veins are compressed and kinked, so blood cannot return to the right heart. Cardiac output falls, causing hypotension and tachycardia, while blood backs up in the systemic veins, causing jugular venous distension. Tracheal deviation away from the affected side may appear late. This is an obstructive form of shock and can progress to cardiac arrest within minutes.

| Finding | Simple pneumothorax | Tension pneumothorax |
| --- | --- | --- |
| Absent breath sounds on affected side | Present | Present |
| Hyperresonance on percussion | Present | Present |
| Sharp pleuritic chest pain | Present | Present |
| Hypotension with distended neck veins | Absent | Present: impaired venous return |
| Tracheal deviation away from the affected side | Absent | May occur, often late |

Why the other findings do not discriminate
Watch out! Absent breath sounds, hyperresonance, and sudden pleuritic pain are real signs of pneumothorax, so they are tempting. However, they reflect air in the pleural space, which is present in both conditions. They confirm a pneumothorax but do not tell the nurse whether pressure is building to the point of compromising circulation.

Immediate nursing actions
The nurse first relieves the obstruction by repositioning him off the tubing and straightening the kink, checks that the drainage system is functioning, and calls for urgent help. Oxygen is given and vital signs, saturation, and neck veins are monitored. If signs of tension persist, the physician performs immediate needle or finger decompression and the chest tube is replaced or cleared. Prevention includes keeping tubing free of kinks and dependent loops and checking it whenever the client changes position.

Exam takeaway
Key point! Signs of air in the chest occur in both simple and tension pneumothorax; signs of circulatory compromise, especially hypotension with distended neck veins, define tension. Tension pneumothorax is a clinical diagnosis that needs decompression without waiting for an X-ray.

## 임상 시나리오

Tension vs Simple PneumothoraxFinding the sign that changes the priority
Absent breath sounds, hyperresonance, and pleuritic pain occur in both simple and tension pneumothorax.

In tension, rising pressure shifts the mediastinum and impairs venous return, causing hypotension and distended neck veins. This is obstructive shock.

Relieve the kink at once, call for urgent help, give oxygen, and prepare for immediate decompression.

CautionDo not wait for a chest X-ray to treat a suspected tension pneumothorax. Keep chest tubing free of kinks and dependent loops at every position change.

## 핵심 개념

- **Tension pneumothorax** — Trapped pleural air under rising pressure that shifts the mediastinum and impairs venous return.
- **Jugular venous distension** — Visible swelling of the neck veins from increased venous pressure.
- **Obstructive shock** — Shock caused by a physical obstruction to blood flow, such as tension pneumothorax.
- **Hyperresonance** — A loud, low-pitched percussion note over air-filled spaces such as a pneumothorax.
- **Needle decompression** — Emergency insertion of a needle into the pleural space to release trapped air.

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