Respiratory Emergencies: Pneumothorax, Hemothorax, ARDS & Respiratory Failure — NCLEX Nursing Lesson Anatomy & Physiology · RN Track · Medical-Surgical Body Systems · Respiratory System · Respiratory Emergencies Condition Lesson · NCLEX-PN / NCLEX-RN

When breathing fails fast—air in the chest, blood in the chest, flooded lungs, or lungs that simply can't keep up. The reasoning behind chest tubes, PEEP, proning, and every life-saving priority.

In this lesson

Lesson Objectives
Why This Matters
Disease Overview
Pathophysiology
Risk Factors
Signs & Symptoms
Nursing Assessment
Diagnostic Tests
Laboratory Tests
Medications
Chest Tube Care (key)
Nursing Interventions
Complications
Patient Education
Clinical Judgment
Clinical Connections
NCLEX High-Yield
Memory Aids
Case Study
Practice Questions
Key Takeaways
References

Lesson Objectives

Differentiate pneumothorax (incl. tension), hemothorax, ARDS, and respiratory failure by cause and hallmark finding.
Recognize tension pneumothorax as an immediate emergency and describe needle decompression.
Provide safe chest-tube care—what's normal, what's dangerous, and what to do if it dislodges or disconnects.
Explain ARDS (refractory hypoxemia) and the reasoning behind PEEP, low-tidal-volume ventilation, and proning.
Interpret ABGs to identify hypoxemic vs. hypercapnic respiratory failure and apply clinical judgment to NGN items.

Why This Matters

Prevalence: these are the respiratory conditions that turn deadly fast. Pneumothorax and hemothorax follow chest trauma, procedures, and lung disease; ARDS complicates severe pneumonia, sepsis, aspiration, and trauma; and respiratory failure is the final common endpoint of many lung problems. You'll encounter them in the ED, ICU, trauma, and post-op units.

Patient safety: all four impair oxygenation and can cause death within minutes to hours. Tension pneumothorax can arrest circulation; a massive hemothorax causes hemorrhagic shock; ARDS causes refractory hypoxemia; and untreated respiratory failure ends in cardiac arrest. Rapid recognition and airway/oxygenation support are life-saving.

NCLEX importance: heavily tested on airway/oxygenation prioritization, recognizing tension pneumothorax (tracheal deviation, absent breath sounds), chest-tube management (what to do if it dislodges/disconnects, bubbling/tidaling), ARDS ventilator concepts (PEEP, proning), and ABG interpretation. It builds on the A&P of ventilation, gas exchange, and pleural pressures.

Why nurses encounter them constantly: chest tubes, ventilators, and rapid deterioration are ICU/med-surg realities—nurses must recognize emergencies and act in seconds.

Connecting to prior lessons From A&P, recall that the lungs stay inflated because the pleural space has negative pressure; air (pneumothorax) or blood (hemothorax) in that space collapses the lung. Gas exchange happens at the alveoli—ARDS floods them. From assessment, recall that airway and oxygenation are always the priority and that SpO₂, breath sounds, and work of breathing are the vital cues.

Disease Overview

Emergency	What it is (one line)	Core danger
Pneumothorax	Air enters the pleural space → the lung collapses	Lung collapse → hypoxia; tension type is rapidly fatal
Tension pneumothorax	Air keeps entering and can't escape (one-way valve) → pressure builds, shifting the mediastinum	Compresses the heart/great vessels → obstructive shock & arrest
Hemothorax	Blood collects in the pleural space (often trauma)	Lung collapse + hemorrhagic shock from blood loss
ARDS	Acute Respiratory Distress Syndrome—diffuse alveolar injury flooding the alveoli	Refractory hypoxemia (low O₂ that doesn't respond to oxygen)
Respiratory failure	The lungs can't maintain oxygenation and/or ventilation	Type I (hypoxemic, ↓O₂) or Type II (hypercapnic, ↑CO₂) → arrest

Analogy — the sealed vacuum bag

Healthy lungs stay expanded like a vacuum-sealed bag—the negative pressure in the pleural space holds them open. Pneumothorax pokes a hole and lets air in, so the "bag" (lung) collapses. Tension is a one-way valve that keeps pumping air in with each breath until the pressure crushes the heart. Hemothorax fills the space with blood instead of air. ARDS is different—the tiny air sacs themselves flood, so oxygen can't cross no matter how much you give. Respiratory failure is the end state: the system can't keep up.

Pathophysiology

Normal physiology: negative pleural pressure keeps the lungs inflated; alveoli exchange O₂ and CO₂; the respiratory system matches ventilation to the body's needs. ↓ Pneumothorax: a breach (trauma, ruptured bleb, procedure, or spontaneous) lets air into the pleural space → the negative pressure is lost → the lung collapses → decreased breath sounds, dyspnea, and hypoxia on that side. ↓ Tension pneumothorax: air enters but can't escape → pressure rises with each breath → the mediastinum and trachea shift to the opposite side, compressing the heart and great vessels → decreased venous return, obstructive shock, hypotension, and arrest. ↓ Hemothorax: bleeding into the pleural space (chest trauma, vessel injury) → the lung is compressed by blood and the patient loses circulating volume → dyspnea + signs of hemorrhagic shock (tachycardia, hypotension). ↓ ARDS: a severe insult (sepsis, aspiration, pneumonia, trauma) → inflammation damages the alveolar-capillary membrane → the alveoli flood with protein-rich fluid and surfactant fails → stiff, wet lungs and refractory hypoxemia (hypoxia that persists despite high oxygen). ↓ Respiratory failure: any of these (or COPD/asthma, drug overdose, neuromuscular disease) overwhelm the lungs → Type I (hypoxemic: low PaO₂) or Type II (hypercapnic: high PaCO₂ with acidosis) → without support, cardiac arrest. NCLEX Clinical Pearl — tracheal deviation = tension Tension pneumothorax is the can't-miss emergency: tracheal deviation AWAY from the affected side, absent breath sounds on the affected side, severe dyspnea, hypotension, distended neck veins, and cyanosis. It requires immediate needle decompression (2nd intercostal space, midclavicular line) followed by a chest tube—don't wait for imaging.

Risk Factors

Non-modifiable	Modifiable	Preventable / reducible
Tall, thin body habitus (spontaneous pneumothorax) Underlying lung disease (COPD/emphysema—bleb rupture) Older age/chronic illness (respiratory failure risk)	Smoking (bleb formation) High-risk activities (chest trauma) Untreated severe infection/sepsis (ARDS)	Seatbelts/safety (trauma → pneumo/hemothorax) Early sepsis/pneumonia/aspiration treatment (prevent ARDS) Careful procedures (central lines, thoracentesis)

High-risk populations: trauma patients (pneumo/hemothorax), tall thin young adults and smokers/COPD (spontaneous pneumothorax), patients undergoing central-line placement/thoracentesis (iatrogenic pneumothorax), and critically ill patients with sepsis, aspiration, severe pneumonia, or major trauma (ARDS/respiratory failure).

Signs & Symptoms

Emergency	Hallmark findings & WHY
Pneumothorax	Sudden sharp pleuritic chest pain, dyspnea, decreased/absent breath sounds and hyperresonance on the affected side, tachypnea, and low SpO₂. The collapsed lung can't exchange gas.
Tension pneumothorax (emergency)	Severe dyspnea, absent breath sounds one side, tracheal deviation AWAY from the affected side, distended neck veins (JVD), hypotension, tachycardia, and cyanosis. Rising pressure compresses the heart → obstructive shock.
Hemothorax	Dyspnea, decreased breath sounds and dullness to percussion on the affected side, and signs of shock (tachycardia, hypotension, pallor) from blood loss.
ARDS	Severe, rapidly worsening dyspnea and hypoxemia that does NOT improve with supplemental oxygen (refractory hypoxemia), tachypnea, crackles, and anxiety/restlessness; bilateral infiltrates on x-ray. Flooded alveoli block gas exchange.
Respiratory failure	Dyspnea, tachypnea then bradypnea/fatigue, use of accessory muscles, cyanosis, restlessness → confusion/decreased LOC, and abnormal ABGs. The patient is tiring and can no longer maintain gas exchange.
Emergency findings (all)	Falling SpO₂, severe respiratory distress, cyanosis, confusion/decreasing LOC, hypotension, and impending arrest.

Why restlessness & confusion are ominous Early hypoxia often shows as restlessness and anxiety; as it worsens, the patient becomes confused, then lethargic—the brain is starving for oxygen. A "calming down" patient who is actually becoming drowsy with a falling SpO₂ is deteriorating, not improving. Trust the numbers and the trend.

Nursing Assessment

Subjective: onset of pain/dyspnea, mechanism (trauma, procedure, sudden), underlying lung disease, and recent critical illness (sepsis, aspiration) suggesting ARDS.

Objective: vital signs with SpO₂, respiratory rate/effort, breath sounds (absent/decreased? which side?), tracheal position, chest symmetry/expansion, percussion (hyperresonance = air; dullness = blood), JVD, skin color, mental status, and ABGs. For chest-tube patients: assess the drainage system.

Priority / focused finding	Why it matters / action
Airway/oxygenation (SpO₂, work of breathing)	The top priority—act on the airway/oxygenation immediately.
Tracheal deviation + absent breath sounds + hypotension/JVD	Tension pneumothorax—immediate needle decompression; call for help now.
Signs of shock (hemothorax)	Hemorrhage—fluids/blood, chest tube, and rapid escalation.
Refractory hypoxemia despite O₂	ARDS—anticipate intubation, PEEP, proning; escalate to ICU.
Mental status & ABG trend	Confusion/rising CO₂ or falling pH = respiratory failure—support ventilation.

When to notify / act now Absent breath sounds with tracheal deviation and hypotension (tension pneumothorax), signs of shock with a hemothorax, refractory hypoxia (ARDS), rising CO₂ with a falling pH or declining LOC (respiratory failure), or a dislodged/disconnected chest tube. These are seconds-to-minutes emergencies.

Diagnostic Tests

Test	Purpose / why ordered	Findings & nursing considerations
Chest X-ray/CT	Confirm air (pneumothorax), blood (hemothorax), or bilateral infiltrates (ARDS)	Air/lung collapse (pneumo), fluid/blunting (hemo), diffuse bilateral "white-out" (ARDS). Tension pneumothorax is a clinical diagnosis—treat before imaging.
ABG	Assess oxygenation/ventilation and classify respiratory failure	Low PaO₂ (Type I) vs. high PaCO₂ with acidosis (Type II). ARDS shows severe hypoxemia (low PaO₂/FiO₂ ratio).
Pulse oximetry/continuous monitoring	Track oxygenation trend	Falling SpO₂ signals deterioration—escalate.
Bedside ultrasound (eFAST/lung)	Rapid detection of pneumothorax/hemothorax in trauma	Fast, at the bedside; supports urgent decisions.
Post-procedure chest x-ray	Confirm chest-tube placement and lung re-expansion	Verify after insertion and after any change.

Laboratory Tests

Test	Normal / expected	Significance
ABG — PaO₂ / PaCO₂ / pH	PaO₂ 80–100; PaCO₂ 35–45; pH 7.35–7.45	Type I failure = ↓PaO₂; Type II = ↑PaCO₂ with ↓pH (respiratory acidosis). ARDS = severe refractory hypoxemia. Trend it—priority.
PaO₂/FiO₂ ratio (ARDS)	Normal >400	A low ratio (≤300) defines ARDS severity—the lower, the worse.
CBC (H&H)	Hgb 12–17 g/dL	Falling H&H = blood loss (hemothorax/hemorrhage)—monitor and replace.
Lactate	<2 mmol/L	Elevated = tissue hypoxia/shock (tension pneumo, hemothorax, ARDS)—escalate.
Coagulation studies	Per lab	Assess bleeding risk before chest tube/procedures.

Trend interpretation The critical trend is the ABG/oxygenation. In respiratory failure, a rising CO₂ with a falling pH and a tiring patient means ventilation is failing—support it. In ARDS, a falling PaO₂/FiO₂ ratio means worsening. A falling H&H in trauma signals ongoing hemorrhage.

Medications / Therapies

Purpose	Agent/therapy & why
Oxygenation	Supplemental oxygen; escalate to high-flow, non-invasive (BiPAP), or mechanical ventilation with PEEP as needed—support gas exchange.
Sedation/analgesia (ventilated patients)	Sedatives (e.g., propofol, dexmedetomidine) and analgesics (opioids) for comfort and vent tolerance; monitor for hypotension/oversedation.
Neuromuscular blockade (severe ARDS)	Paralytics (e.g., cisatracurium) may be used briefly to improve ventilation/oxygenation—always with sedation (paralysis without sedation is inhumane and dangerous).
Treat the cause	Antibiotics (sepsis/pneumonia driving ARDS), blood products/fluids (hemothorax/shock), bronchodilators for reversible obstruction.
Vasopressors	Support blood pressure in shock (tension pneumo, hemothorax, severe ARDS)—after addressing the cause.

Safety — paralytics require sedation If a patient receives a neuromuscular blocker, they are paralyzed but can still feel and hear—they must be adequately sedated and their airway/ventilator fully supported. This is a critical safety and ethical point. NCLEX testing points Tension pneumothorax → needle decompression then chest tube. Hemothorax → chest tube + volume/blood. ARDS → intubation, PEEP, low-tidal-volume ventilation, proning; treat the cause. Respiratory failure → support oxygenation/ventilation. Paralytics require sedation.

Chest Tube Care — the high-yield skill

A chest tube drains air (pneumothorax) or blood/fluid (hemothorax) from the pleural space to re-expand the lung. Nursing management is a top NCLEX topic.

What you see	Normal vs. concerning & WHY
Tidaling (fluid rises/falls with breathing in the water-seal chamber)	Normal—reflects pressure changes; stops when the lung re-expands or if the tube is blocked/kinked (check patency).
Bubbling in the water-seal chamber	Intermittent bubbling with a pneumothorax is expected (air leaving). Continuous/new bubbling = an air leak in the system or patient—investigate.
Bubbling in the suction-control chamber	Gentle, continuous bubbling is normal (shows suction is working)—vigorous bubbling isn't necessary.
Drainage amount/color	Monitor and record; >100 mL/hr of bright-red drainage (or a sudden large increase) = hemorrhage—notify the surgeon.
System position	Keep the drainage system below chest level and upright; keep tubing free of kinks/dependent loops.

Emergencies — what to do if the tube dislodges or disconnects

If the chest tube comes OUT of the patient (dislodges): immediately cover the site with a sterile occlusive dressing taped on three sides (a flutter-valve effect that lets air escape but not enter), and notify the provider. (Some facilities apply a dry sterile dressing and call—follow policy; the goal is to prevent air from entering.)
If the tube DISCONNECTS from the drainage system: submerge the end in sterile water to restore the water seal, then notify the provider.
Do NOT routinely clamp a chest tube—clamping can trap air and cause a tension pneumothorax.

Why you don't clamp a chest tube Clamping stops air/fluid from escaping. If the patient still has an air leak, that trapped air builds pressure and can cause a tension pneumothorax. Keep the system open and below chest level; report continuous bubbling and sudden changes.

Nursing Interventions

Priority	Intervention & WHY
Airway	Ensure a patent airway; prepare for intubation in severe cases—everything depends on the airway.
Breathing/oxygenation	High Fowler's position, apply oxygen and escalate (high-flow/BiPAP/ventilation with PEEP); for tension pneumothorax, anticipate immediate needle decompression + chest tube.
Circulation	Treat shock—IV fluids/blood (hemothorax), vasopressors as needed; monitor BP, HR, perfusion, and lactate.
Chest-tube management	Monitor drainage, tidaling, and bubbling; keep the system below chest level and patent; know the dislodge/disconnect emergency steps.
ARDS support	Anticipate/assist with low-tidal-volume ventilation, PEEP, and proning; treat the underlying cause; monitor oxygenation.
Safety	Continuous monitoring, sedation safety (with paralytics), fall/injury prevention with altered LOC.
Comfort	Pain control (chest tube/trauma), reduce anxiety, and support the patient and family through a frightening event.
Education	Explain procedures/equipment, and (for at-risk/recovering patients) warning signs and follow-up.
Interdisciplinary	Respiratory therapy, intensivist/pulmonology, trauma/surgery, and ICU team.

Why proning helps in ARDS Turning an ARDS patient face-down (proning) improves oxygenation by recruiting collapsed dorsal (back) lung regions and better matching ventilation to perfusion. Combined with low-tidal-volume ventilation and PEEP (which keeps flooded alveoli open), it's a physiology-based rescue for refractory hypoxemia.

Potential Complications

Complication	Early signs	Nursing / emergency response
Tension pneumothorax	Tracheal deviation, absent breath sounds, JVD, hypotension, cyanosis	Emergency: immediate needle decompression, then chest tube; call for help—do not delay for x-ray.
Hemorrhagic shock (hemothorax)	Tachycardia, hypotension, pallor, >100 mL/hr bloody chest-tube output	Emergency: fluids/blood, notify surgeon, prepare for surgery.
Refractory hypoxemia / multi-organ failure (ARDS)	Persistent low SpO₂ despite high O₂, worsening organ function	Ventilator optimization (PEEP), proning, treat cause; ICU.
Cardiac/respiratory arrest	Severe hypoxia, bradypnea, unresponsiveness	Emergency: BLS/ACLS, secure airway, ventilate.
Chest-tube dislodgement/disconnection	Tube out or off, air leak, worsening distress	Occlusive dressing (3 sides) if out; water seal if disconnected; notify provider.
Ventilator-associated complications (VAP, barotrauma)	New fever/infiltrate; sudden desaturation/pneumothorax	VAP-prevention bundle; recognize and treat barotrauma.

Patient Education

Disease process: explain what happened (air/blood in the chest, flooded lungs, or failing breathing) and the equipment (chest tube, ventilator) in plain terms. Prevention/lifestyle: stop smoking (reduces bleb/COPD-related pneumothorax), use safety measures to prevent trauma, and seek early care for infections (to prevent ARDS). During recovery: deep-breathing/incentive spirometry and gradual activity to re-expand the lung; keep the chest-tube system below chest level and report problems. Home care (post-discharge): avoid air travel/scuba until cleared after a pneumothorax, avoid heavy lifting/straining as advised, and care for the healing site. Follow-up: keep imaging/pulmonology appointments. Warning signs / when to seek emergency care: sudden or worsening shortness of breath, chest pain, coughing blood, fever, or low oxygen readings—seek emergency care.

Clinical Judgment (NCSBN Model)

Recognize cues: a trauma patient with a chest injury suddenly develops severe dyspnea, absent breath sounds on the left, tracheal deviation to the right, distended neck veins, BP 80/50, HR 130, and cyanosis.
Analyze cues: absent breath sounds + tracheal deviation away from the affected side + JVD + hypotension = tension pneumothorax—air trapped under pressure is compressing the heart (obstructive shock). This is a can't-wait emergency.
Prioritize hypotheses: tension pneumothorax causing obstructive shock—relieving the pressure and supporting oxygenation/circulation is the immediate priority.
Generate solutions: call for help/Rapid Response, apply high-flow oxygen, prepare for immediate needle decompression (2nd intercostal space, midclavicular line) followed by chest-tube insertion, and support circulation.
Take action: assist with needle decompression/chest tube without delay, give oxygen, support BP, and monitor continuously.
Evaluate outcomes: did breath sounds return, the trachea recenter, BP rise, and SpO₂ improve after decompression? Confirm chest-tube function and re-expansion; continue monitoring.

Clinical Connections — commonly confused conditions

	Pneumothorax	Tension pneumothorax	Hemothorax
What's in the pleural space	Air	Air under building pressure (one-way valve)	Blood
Percussion	Hyperresonant	Hyperresonant	Dull
Key signs	Sudden pain, dyspnea, decreased sounds	Tracheal deviation, JVD, hypotension	Decreased sounds + shock from blood loss
Priority treatment	Chest tube; O₂	Immediate needle decompression → chest tube	Chest tube + blood/fluids

	ARDS	Type II (hypercapnic) respiratory failure
Core problem	Alveoli flood → refractory hypoxemia (low O₂ despite oxygen)	Ventilation fails → CO₂ retention (high PaCO₂, acidosis)
ABG	Severe ↓PaO₂; low PaO₂/FiO₂ ratio	↑PaCO₂ with ↓pH
Treatment	Intubation, PEEP, low tidal volume, proning; treat cause	Support ventilation (BiPAP/vent), treat cause
Priority nursing	Oxygenation, ventilator support, positioning	Ventilation/CO₂ removal, LOC monitoring

Key discriminators: hyperresonance = air (pneumothorax); dullness = blood (hemothorax); tracheal deviation + shock = tension; refractory hypoxemia with bilateral infiltrates = ARDS.

NCLEX High-Yield Review

What the NCLEX Wants You to Know

Tension pneumothorax = needle decompression Tracheal deviation, absent sounds, JVD, hypotension—act now.
Don't clamp a chest tube Clamping can cause a tension pneumothorax.
Chest tube out → occlusive dressing (3 sides) Disconnected → submerge in sterile water.
ARDS = refractory hypoxemia PEEP, low tidal volume, proning; treat the cause.
Restlessness/confusion = worsening hypoxia Trust the trend, not a "calming" patient.

Common distractors: clamping a chest tube for transport or a leak, waiting for an x-ray before treating a tension pneumothorax, being reassured by a quieting/drowsy hypoxic patient, and thinking oxygen alone will fix ARDS. Priority interventions: airway/oxygenation, relieve tension pneumothorax immediately, chest-tube management, ventilator/PEEP/proning for ARDS, and shock support. Expected vs unexpected: intermittent water-seal bubbling and tidaling are expected with a pneumothorax; continuous bubbling (leak), >100 mL/hr bloody output, tracheal deviation, or refractory hypoxia are emergencies. Patient teaching: deep breathing, no clamping/keep system below chest, avoid flying/diving after pneumothorax, warning signs. Safety: chest-tube emergencies, sedation with paralytics, continuous monitoring. Delegation: RN assesses and manages emergencies and the chest-tube system; UAP can take vitals, help with positioning/comfort, and report changes—not manage the chest tube or interpret findings. Frequently tested therapies: chest tube, needle decompression, PEEP/proning, oxygen, blood/fluids; critical values: ABG (PaO₂/PaCO₂/pH), PaO₂/FiO₂ ratio, H&H, lactate. Most common mistakes: clamping chest tubes, delaying tension-pneumothorax treatment, and misreading deteriorating LOC.

Memory Aids

Tension pneumo = "Trachea points away, patient's going down" — deviation away from the affected side + hypotension/JVD → needle decompress.
Percussion "Air is Airy (hyperresonant), Blood is Blunt (dull)."
Chest tube "Never clamp, keep it below, watch the bubbles."
Dislodged tube = "3-sided dressing"; disconnected = "sterile water."
ARDS = "Adults Respiratory Distress = Refractory hypoxemia + PEEP + Prone."
Respiratory failure "Type 1 = low Oxygen; Type 2 = high CO₂ (Two = COTwo)."
Hypoxia progression "Restless → Confused → Drowsy → Arrest" — earlier is better.

Case Study — from admission to discharge

Admission. Mr. Cole, 28, arrives after a motor-vehicle crash with left-sided chest trauma. He has severe dyspnea, sharp left chest pain, and decreased breath sounds on the left. RR 30, HR 118, BP 104/66, SpO₂ 89%. A chest x-ray confirms a left pneumothorax, and a chest tube is placed.

Step 1–2: Recognize & analyze cues

Cues: chest trauma + sharp pain + decreased left breath sounds + dyspnea + hypoxia = pneumothorax. Priority is oxygenation and lung re-expansion (chest tube).

Step 3–4: Prioritize & plan

Priority: airway/oxygenation and chest-tube management. Plan: high Fowler's, oxygen, assist with chest-tube placement, then monitor the drainage system (tidaling, intermittent bubbling), drainage amount/color, vitals, and SpO₂; pain control; watch for tension pneumothorax.

Step 5: Take action (deterioration)

An hour later he suddenly worsens: absent breath sounds on the left, trachea deviated to the right, JVD, BP 82/50, SpO₂ 84%—the chest tube is found kinked. The nurse recognizes an evolving tension pneumothorax, unkinks/ensures patency, keeps the system below chest level and unclamped, applies high-flow oxygen, and calls for help; needle decompression and chest-tube function are restored.

Step 6: Evaluate & discharge

Breath sounds return, the trachea recenters, BP and SpO₂ improve, and the lung re-expands (tidaling stops, x-ray confirms). The tube is later removed. Discharge teaching: deep breathing/incentive spirometry, gradually resume activity, avoid air travel and scuba diving until cleared, care for the site, and return for sudden dyspnea, chest pain, or fever.

NCLEX Practice Questions

Answer choices are numbered; the correct answer is given as a number.

1. A trauma client suddenly develops absent breath sounds on the right, tracheal deviation to the left, distended neck veins, and hypotension. The nurse recognizes this as a:

Simple pneumothorax
Hemothorax
Tension pneumothorax requiring immediate decompression
Pleural effusion

Rationale

Answer: 3. Tracheal deviation away from the affected side with JVD and hypotension indicates a tension pneumothorax—air under pressure compressing the heart—needing immediate needle decompression. A simple pneumothorax (1) lacks deviation/shock, hemothorax (2) is dull to percussion with blood loss, and effusion (4) develops gradually.

2. A client's chest tube accidentally disconnects from the drainage system. What should the nurse do first?

Clamp the chest tube near the insertion site
Call the provider and wait
Reconnect using clean technique only
Submerge the end of the tube in sterile water

Rationale

Answer: 4. If the tube disconnects, submerge the end in sterile water to re-establish the water seal and prevent air from entering the pleural space, then notify the provider. Clamping (1) can cause a tension pneumothorax; waiting (2) delays care.

3. Which finding in a client with ARDS is the hallmark the nurse expects?

Hypoxemia that improves quickly with supplemental oxygen
Refractory hypoxemia that does not improve with supplemental oxygen
Unilateral wheezing
A normal chest x-ray

Rationale

Answer: 2. ARDS is defined by refractory hypoxemia—low oxygen that persists despite high supplemental oxygen—because flooded alveoli block gas exchange, with bilateral infiltrates on x-ray. Options 1, 3, and 4 are inconsistent with ARDS.

4. A nurse is caring for a client with a chest tube for a pneumothorax. Which finding requires immediate action?

New continuous bubbling in the water-seal chamber with worsening dyspnea
Gentle tidaling in the water-seal chamber
Intermittent bubbling in the water-seal chamber
Gentle continuous bubbling in the suction-control chamber

Rationale

Answer: 1. New continuous bubbling in the water-seal chamber signals an air leak, and worsening dyspnea suggests deterioration—investigate and notify the provider. Tidaling (2), intermittent water-seal bubbling with a pneumothorax (3), and gentle suction-chamber bubbling (4) are expected.

5. A client in respiratory distress becomes increasingly restless and confused with a falling SpO₂. The nurse interprets this as:

The client is calming down
A normal response to hospitalization
A sign the oxygen can be decreased
Worsening hypoxia requiring immediate intervention

Rationale

Answer: 4. Restlessness and confusion with falling SpO₂ indicate worsening hypoxia (the brain is oxygen-starved)—an emergency needing immediate airway/oxygenation support. It is not calming (1), normal (2), or a reason to reduce oxygen (3).

6. SATA. Which are appropriate nursing actions in the care of a client with a chest tube? Select all that apply.

Keep the drainage system below the level of the chest
Routinely clamp the tube during ambulation
Monitor drainage amount and color
Report drainage greater than 100 mL/hr of bright-red blood
Keep an occlusive dressing available in case the tube dislodges

Rationale

Answers: 1, 3, 4, 5. Keeping the system below chest level, monitoring drainage, reporting excessive bloody output, and being ready for dislodgement are correct. Routinely clamping (2) can cause a tension pneumothorax and is avoided.

7. SATA. Which findings indicate a tension pneumothorax? Select all that apply.

Tracheal deviation away from the affected side
Distended neck veins
Hyperresonance and absent breath sounds on the affected side
Hypertension and bradycardia
Severe dyspnea and hypotension

Rationale

Answers: 1, 2, 3, 5. Tracheal deviation, JVD, hyperresonance/absent sounds, and dyspnea with hypotension indicate tension pneumothorax. Hypertension with bradycardia (4) is not typical—tension causes hypotension and tachycardia.

8. Priority. A nurse is caring for four clients. Who should be assessed first?

A client with a stable chest tube and gentle tidaling
A trauma client with absent breath sounds, tracheal deviation, and a BP of 82/48
A client with pneumonia awaiting antibiotics
A client requesting chest-tube discharge teaching

Rationale

Answer: 2. Absent breath sounds, tracheal deviation, and hypotension indicate a tension pneumothorax—an immediate life threat needing decompression. The others are stable or routine.

9. Delegation. Which task can the RN appropriately delegate to unlicensed assistive personnel (UAP) for a stable client with a chest tube?

Assessing the chest-tube drainage system and breath sounds
Managing an air leak in the system
Obtaining vital signs and helping the client reposition while keeping the drainage system below chest level, reporting concerns
Teaching about the chest tube

Rationale

Answer: 3. Taking vitals and assisting with positioning (keeping the system below chest level) are within UAP scope and support safety. Assessing/managing the system (1, 2) and teaching (4) require the licensed nurse.

10. NGN Case Study. A 55-year-old with severe pneumonia and sepsis develops rapidly worsening dyspnea. Despite a non-rebreather at 15 L/min, SpO₂ remains 84%. RR 34, using accessory muscles, restless. Chest x-ray shows bilateral infiltrates ("white-out"). ABG: pH 7.30, PaO₂ 55, PaCO₂ 50.

a) What is developing and which cues support it?
b) What are the priority nursing actions and anticipated interventions?

Model answer

a) What's developing: ARDS with respiratory failure from sepsis/pneumonia. Supporting cues: refractory hypoxemia (SpO₂ 84% and PaO₂ 55 despite a non-rebreather), bilateral infiltrates, severe tachypnea/accessory-muscle use, restlessness (hypoxia), and a low pH with rising CO₂ (the patient is tiring).

b) Priority actions/anticipated interventions: 1) prioritize airway/oxygenation—the refractory hypoxemia and fatigue mean anticipate intubation and mechanical ventilation with PEEP and low tidal volumes; 2) prepare for proning to improve oxygenation; 3) treat the cause (antibiotics/sepsis management, fluids/vasopressors as needed); 4) ensure sedation/analgesia and, if paralytics are used, adequate sedation; 5) continuous monitoring of SpO₂/ABG, hemodynamics, and LOC; notify the provider/Rapid Response and transfer to ICU. Evaluate oxygenation and ventilation after each intervention.

Key Takeaways

Tension pneumothorax (tracheal deviation away from the affected side, absent breath sounds, JVD, hypotension) is an immediate emergency → needle decompression, then chest tube.
Hemothorax = blood in the pleural space (dull to percussion + shock) → chest tube + blood/fluids; pneumothorax = air (hyperresonant) → chest tube.
Chest tube rules: keep the system below chest level, don't routinely clamp, watch tidaling/bubbling; dislodged → occlusive dressing (3 sides); disconnected → sterile water; report >100 mL/hr bright-red drainage.
ARDS = refractory hypoxemia with bilateral infiltrates → intubation, PEEP, low tidal volume, proning, and treat the cause; oxygen alone won't fix it.
Respiratory failure: Type I = hypoxemic (↓O₂); Type II = hypercapnic (↑CO₂ with acidosis)—support oxygenation/ventilation.
Restlessness → confusion → drowsiness reflects worsening hypoxia—act early; a quieting hypoxic patient is deteriorating.
Airway and oxygenation are always the priority; paralytics require sedation.

References

Hinkle, J. L., Cheever, K. H., & Overbaugh, K. J. (2022). Brunner & Suddarth's textbook of medical-surgical nursing (15th ed.). Wolters Kluwer/Lippincott.
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2021). Medical-surgical nursing: Concepts for interprofessional collaborative care (10th ed.). Elsevier.
Silvestri, L. A., & Silvestri, A. E. (2023). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier.
Assessment Technologies Institute. (2023). ATI RN adult medical-surgical nursing review module (12th ed.). ATI Nursing Education.
Grasselli, G., Calfee, C. S., Camporota, L., Poole, D., Amato, M. B. P., Antonelli, M., … Brochard, L. (2023). ESICM guidelines on acute respiratory distress syndrome. Intensive Care Medicine, 49(7), 727–759. https://doi.org/10.1007/s00134-023-07050-7
American Association of Critical-Care Nurses. (2023). Chest tube management & care of the mechanically ventilated patient (AACN practice resources). AACN. https://www.aacn.org
National Heart, Lung, and Blood Institute. (2023). ARDS and respiratory failure. National Institutes of Health. https://www.nhlbi.nih.gov

Respiratory Emergencies

You must be logged in to access this course

Welcome & Getting Started

Launch RN Simulator

Wellness Center

Nursing Foundations

Fundamentals & Safety

Pharmacology

Dosage Calculations

Leadership, Management & Delegation

Medical-Surgical Body Systems

Neurological System

Sensory System

Endocrine System

Respiratory System

Cardiovascular System

Hematologic/Immune/Lymphatic System

Gastrointestinal (GI) System

Renal & Genitourinary

Reproductive System

Musculoskeletal System

Integumentary System

Specialty Areas

Maternity

Infectious Diseases

Pediatrics

Mental Health

NCLEX Success Center

Clinical Judgment Practice

Prioritization Practice

Delegation Practice

Lab Values

Final Review