Pneumothorax and Pleural Disorders Practice Questions

30 multiple-choice questions on Pneumothorax and pleural disorders for paramedic and EMT students, from Chapter 17 (Respiratory Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

30 practice questions

1. In an awake, spontaneously breathing patient, a developing tension pneumothorax usually shows which findings before hypotension?

   1. A. Worsening hypoxia, tachycardia, and distress
   2. B. Bradycardia with a falling respiratory rate first
   3. C. A normal SpO2 and calm breathing
   4. D. Hypertension with slow, deep breaths
   Show answer

   Answer: A. Worsening hypoxia, tachycardia, and distress

   Awake patients usually become progressively hypoxic, tachycardic, and distressed before their BP falls, whereas ventilated patients often drop their BP quickly. Bradycardia and slowing respirations are late, peri-arrest signs. A normal SpO2 and calm breathing do not fit tension physiology. Hypertension with slow breathing is not part of the picture.

2. A secondary spontaneous pneumothorax is one that occurs:

   1. A. Only during mechanical ventilation
   2. B. With underlying lung disease
   3. C. Only in healthy athletes
   4. D. Only after blunt trauma
   Show answer

   Answer: B. With underlying lung disease

   Secondary spontaneous pneumothorax occurs in patients with lung disease such as COPD, cystic fibrosis, or pneumonia and tends to be more serious.

3. You arrive to find a 22-year-old man with sudden sharp right chest pain and mild dyspnea while sitting at his desk. Breath sounds are decreased on the right. What is the most likely diagnosis?

   1. A. Spontaneous pneumothorax
   2. B. Acute asthma exacerbation
   3. C. Acute myocardial infarction
   4. D. Pulmonary edema
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   Answer: A. Spontaneous pneumothorax

   Sudden pleuritic pain with unilateral decreased breath sounds in a young, otherwise healthy man suggests a spontaneous pneumothorax.

4. Which percussion finding over the affected side is expected with a pneumothorax?

   1. A. Normal resonance
   2. B. Dullness
   3. C. Flatness
   4. D. Hyperresonance
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   Answer: D. Hyperresonance

   Air in the pleural space produces a hyperresonant percussion note. Dullness suggests fluid or consolidation.

5. A patient with a small, untreated pneumothorax is to be flown in an unpressurized helicopter to 2,000 m. What is the concern?

   1. A. Low air pressure will seal the leak
   2. B. Cold air at altitude makes the pleural air dissolve
   3. C. Trapped pleural air expands as the altitude rises
   4. D. Altitude has no effect on gas in the chest
   Show answer

   Answer: C. Trapped pleural air expands as the altitude rises

   Gas expands as pressure falls (Boyle's law), so a small pneumothorax can enlarge or turn into a tension pneumothorax during an unpressurized flight; fly low if possible and be ready to decompress. Lower pressure does not seal a leak. Cold does not dissolve pleural air. Altitude does affect trapped gas.

6. You transfer a patient whose chest tube connects to a drainage unit. Which practice is correct?

   1. A. Clamp the chest tube for the whole transport time
   2. B. Lift the unit above her chest when moving her
   3. C. Keep the drainage unit below her chest level
   4. D. Empty the water seal before moving her
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   Answer: C. Keep the drainage unit below her chest level

   Keeping the unit below the chest lets air and fluid drain out and stops fluid from flowing back. Clamping a tube that is draining air can cause a tension pneumothorax. Raising the unit sends fluid back into the chest. The water seal is a one-way valve and must not be emptied.

7. An intubated patient suddenly becomes difficult to ventilate, hypotensive, and hypoxic, with absent breath sounds on the left. What should you suspect first?

   1. A. Fluid overload in the lungs
   2. B. Tension pneumothorax
   3. C. Severe bronchospasm
   4. D. Mucus plug in the tube
   Show answer

   Answer: B. Tension pneumothorax

   Positive-pressure ventilation can rapidly convert a simple pneumothorax into a tension pneumothorax. Also consider tube displacement and obstruction using the DOPE mnemonic.

8. What is the definitive prehospital intervention for a tension pneumothorax with hemodynamic compromise?

   1. A. Nebulized albuterol
   2. B. CPAP at 10 cm H2O
   3. C. High-flow oxygen by NRB
   4. D. Needle decompression
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   Answer: D. Needle decompression

   Needle decompression releases trapped air and can rapidly restore cardiac output. Oxygen alone does not relieve the pressure.

9. Which site is acceptable for needle decompression per current guidelines and many protocols?

   1. A. 6th ICS, along the sternal border
   2. B. 5th ICS, just left of the sternum
   3. C. 4th or 5th ICS, anterior axillary line
   4. D. 2nd ICS, posterior axillary line
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   Answer: C. 4th or 5th ICS, anterior axillary line

   The 2nd intercostal space at the midclavicular line and the 4th or 5th intercostal space at the anterior or mid-axillary line are both used. Follow local protocol.

10. When performing needle decompression at the 2nd intercostal space, midclavicular line, where should the needle enter?

    1. A. Over the top of the third rib
    2. B. Under the bottom of the second rib
    3. C. Through the middle of the sternum
    4. D. Just lateral to the nipple line
    Show answer

    Answer: A. Over the top of the third rib

    Entering just over the superior border of the rib avoids the intercostal vessels and nerve, which run along the inferior rib margin.

11. Why is a needle of at least 3.25 inches (about 8 cm) commonly recommended for adult needle decompression?

    1. A. Longer needles have a wider bore
    2. B. Shorter needles cause bleeding
    3. C. Shorter needles may not reach
    4. D. Shorter needles may puncture the heart
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    Answer: C. Shorter needles may not reach

    Studies show chest wall thickness often exceeds the length of shorter catheters, leading to failed decompression. Bore is set by the gauge, not the length, and the concern with short needles is falling short of the pleura, not puncturing the heart; bleeding is not the reason either.

12. After needle decompression, the patient's condition improves and then worsens again 10 minutes later. What is the most likely cause?

    1. A. The patient is hyperventilating
    2. B. The catheter is occluded
    3. C. The oxygen tank is empty
    4. D. The lung has fully re-expanded
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    Answer: B. The catheter is occluded

    Catheters often kink or become occluded. Reassess and repeat decompression per protocol if tension signs recur.

13. After a coughing fit, a 19-year-old has sharp chest pain and crackling under the skin of his neck. His BP and SpO2 are normal, and breath sounds are equal. What is the most likely cause?

    1. A. Spontaneous pneumomediastinum
    2. B. A tension pneumothorax
    3. C. An acute myocardial infarction
    4. D. A pleural effusion
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    Answer: A. Spontaneous pneumomediastinum

    Air that escapes from alveoli can track into the mediastinum and neck after coughing, vomiting, asthma, or drug inhalation, causing chest pain and subcutaneous air; it is usually benign when vital signs are normal. A tension pneumothorax causes one-sided absent breath sounds and shock. An MI does not cause subcutaneous air. An effusion causes dullness, not neck crepitus.

14. A patient with a small spontaneous pneumothorax is to be observed in the hospital. Why is high-concentration oxygen often given?

    1. A. It speeds reabsorption of the pleural air
    2. B. It seals the small hole in the lung surface
    3. C. It prevents tension from ever developing
    4. D. It treats the pain of the pneumothorax
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    Answer: A. It speeds reabsorption of the pleural air

    Breathing high-concentration oxygen washes nitrogen out of the blood, increasing the gradient for absorbing pleural air several-fold. It does not seal the leak, it cannot guarantee that tension will not develop, and it is not an analgesic.

15. A 71-year-old with lung cancer has increasing dyspnea, dull percussion, and decreased breath sounds at the right base. What is most likely?

    1. A. Tension pneumothorax
    2. B. Epiglottitis
    3. C. Pleural effusion
    4. D. Bronchospasm
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    Answer: C. Pleural effusion

    Malignancy commonly causes pleural effusions, which produce dullness and decreased breath sounds over the fluid.

16. Which position is often most comfortable for a patient with a large unilateral pleural effusion?

    1. A. Supine
    2. B. Upright
    3. C. Prone
    4. D. Trendelenburg
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    Answer: B. Upright

    Sitting upright lets the fluid settle at the base and improves ventilation of the upper lung zones.

17. Pleurisy (pleuritis) classically causes:

    1. A. Burning epigastric pain
    2. B. Dull, crushing pressure
    3. C. Tearing pain to the back
    4. D. Sharp pain on inspiration
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    Answer: D. Sharp pain on inspiration

    Inflamed pleural surfaces rub together, causing sharp, stabbing pain that worsens with breathing or coughing.

18. Which breath sound may be heard with pleural inflammation?

    1. A. Pleural friction rub
    2. B. Bronchial rhonchi
    3. C. Inspiratory stridor
    4. D. Expiratory wheezing
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    Answer: A. Pleural friction rub

    A friction rub is a grating or creaking sound from inflamed pleural surfaces rubbing together.

19. Why do many current trauma guidelines favor the 4th or 5th intercostal space at the anterior axillary line for adult needle decompression?

    1. A. The lung apex is safest to puncture
    2. B. The heart lies directly beneath the site
    3. C. Air collects there first when supine
    4. D. The chest wall there is usually thinner
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    Answer: D. The chest wall there is usually thinner

    CT studies show the chest wall at the lateral site is thinner in most adults, so a standard catheter is more likely to reach the pleural space than at the 2nd intercostal space, midclavicular line. The site is not chosen to puncture the apex. The heart lies medial to this site, not under it. In a supine patient air collects anteriorly, which is why the 2nd ICS site is still used in some protocols.

20. Which factor increases the risk of recurrence after a spontaneous pneumothorax?

    1. A. Continued smoking
    2. B. A short, heavy body build
    3. C. Flying after the lung healed
    4. D. Daily walking
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    Answer: A. Continued smoking

    Smoking significantly increases the risk of both initial and recurrent spontaneous pneumothorax. Primary spontaneous pneumothorax favors tall, thin people, and air travel after full resolution does not raise recurrence.

21. A 25-year-old with a prior spontaneous pneumothorax plans to go scuba diving. Why is this concerning?

    1. A. Pressure changes risk recurrence
    2. B. Nitrogen narcosis is more likely
    3. C. Salt water irritates the pleura
    4. D. Pleural scars block gas exchange
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    Answer: A. Pressure changes risk recurrence

    Pressure changes during diving and flying can expand residual blebs and cause recurrence or tension pneumothorax. Nitrogen narcosis is unrelated to a prior pneumothorax, pleural scarring does not block gas exchange, and salt water does not reach the pleura.

22. A patient with COPD develops sudden severe dyspnea and decreased breath sounds on the left. Why is pneumothorax more dangerous in this patient?

    1. A. His lungs re-expand very quickly
    2. B. He has little respiratory reserve
    3. C. He cannot develop a tension physiology
    4. D. He is immune to hypoxemia
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    Answer: B. He has little respiratory reserve

    Patients with limited reserve tolerate even a small pneumothorax poorly and can rapidly decompensate.

23. A retired shipyard worker has a large one-sided pleural effusion and weight loss. Which past exposure is most important to ask about?

    1. A. Asbestos
    2. B. Cotton dust
    3. C. Wood smoke
    4. D. Noise exposure
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    Answer: A. Asbestos

    Asbestos exposure, common in shipbuilding, causes mesothelioma, a cancer of the pleura that often presents decades later as a one-sided effusion with weight loss. Cotton dust and wood smoke cause airway disease rather than pleural cancer. Noise exposure affects hearing.

24. Which of the following can cause a pneumothorax as a complication of a medical procedure?

    1. A. Lumbar puncture
    2. B. Arterial line in the wrist
    3. C. Central line placement
    4. D. Peripheral IV in the hand
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    Answer: C. Central line placement

    Subclavian and internal jugular line placement, thoracentesis, and positive-pressure ventilation can cause iatrogenic pneumothorax. A lumbar puncture, a radial arterial line and a hand IV are far from the pleura.

25. A patient with a simple pneumothorax is stable with an SpO2 of 95% on room air. What is the most appropriate prehospital care?

    1. A. Start CPAP therapy
    2. B. Immediate intubation
    3. C. Needle decompression
    4. D. Monitor and transport
    Show answer

    Answer: D. Monitor and transport

    Stable simple pneumothorax requires monitoring for deterioration, oxygen as needed, and transport. CPAP and positive pressure can worsen a pneumothorax.

26. A patient with a vented chest seal over a gunshot wound becomes more short of breath, with falling SpO2 and rising heart rate. What should you do first?

    1. A. Add a second seal on top of the first
    2. B. Tape the seal down firmly on four sides
    3. C. Burp the seal by lifting one edge
    4. D. Remove the seal and leave the wound open
    Show answer

    Answer: C. Burp the seal by lifting one edge

    Blood can clog a vented seal and trap air, so worsening distress suggests a developing tension pneumothorax; lift an edge to let air escape and decompress if signs persist. A second seal or taping it down traps more air. Removing the seal leaves an open wound, while burping it releases the air and keeps the dressing in place.

27. You hear a grating rub with each breath. When the patient holds his breath, the rub disappears. Where is it coming from?

    1. A. The pericardium
    2. B. The large airways
    3. C. The pleura
    4. D. The chest wall muscles
    Show answer

    Answer: C. The pleura

    A pleural friction rub depends on the lung surfaces moving, so it stops when breathing stops. A pericardial rub follows the heartbeat and continues during breath-holding. Large-airway sounds are rhonchi or wheezes, not a grating rub. Muscle does not make a rhythmic rub with breathing.

28. Which finding on the monitor may accompany worsening tension pneumothorax in an intubated patient?

    1. A. A rising blood glucose
    2. B. A wider QRS complex
    3. C. Rising airway pressures
    4. D. Falling heart rate first
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    Answer: C. Rising airway pressures

    Increased resistance to bagging or rising peak airway pressures, with hypotension and hypoxia, suggests tension pneumothorax.

29. During a transfer, a patient's chest tube is accidentally pulled out. Air hisses from the site with each breath. What should you do first?

    1. A. Push the tube back into the chest
    2. B. Leave the site open to the room air
    3. C. Pack the hole with dry gauze
    4. D. Cover it with an occlusive dressing
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    Answer: D. Cover it with an occlusive dressing

    An open chest tube site can suck in air like an open chest wound, so cover it with an occlusive (or vented) dressing, watch for tension, and burp the dressing or decompress if signs develop. Reinserting a contaminated tube in the field is not done. Leaving it open allows air to enter the chest. Dry gauze does not seal the hole.

30. A pneumothorax that is large enough to require a chest tube is usually managed in the hospital. What is the purpose of the chest tube?

    1. A. To seal the leak in the lung
    2. B. To drain air so the lung re-expands
    3. C. To provide oxygen directly to alveoli
    4. D. To drain blood from the airways
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    Answer: B. To drain air so the lung re-expands

    A chest tube drains air or fluid from the pleural space, allowing the lung to re-expand. The tube sits in the pleural space, not the airway or lung tissue, so it does not seal the lung or drain the airways, and it does not deliver oxygen.