Pneumothorax: Simple, Open (sucking Chest Wound and Vented Chest Seals), and Tension Practice Questions

25 multiple-choice questions on Pneumothorax: simple, open (sucking chest wound and vented chest seals), and tension for paramedic and EMT students, from Chapter 36 (Chest Trauma). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A trauma patient has equal breath sounds on both sides in a noisy ambulance. Regarding pneumothorax, this finding:

   1. A. Rules out a tension pneumothorax
   2. B. Does not rule out a pneumothorax
   3. C. Confirms that both lungs are expanded
   4. D. Makes a pneumothorax unlikely here
   Show answer

   Answer: B. Does not rule out a pneumothorax

   Small pneumothoraces often cause no detectable change in breath sounds, especially in a moving ambulance, and can enlarge later, particularly with positive-pressure ventilation or air transport. Keep monitoring work of breathing, SpO2, and ETCO2. Equal sounds heard in a noisy unit neither confirm full expansion nor exclude a developing tension pneumothorax, and they do little to lower the likelihood of a small one.

2. A 24-year-old fell onto a fence rail. He has pleuritic pain, mild dyspnea, and diminished breath sounds on the right. His BP is 132/84 mmHg, the trachea is midline, and the SpO2 is 94%. The most likely injury is:

   1. A. Tension pneumothorax
   2. B. Massive hemothorax
   3. C. Cardiac tamponade
   4. D. Simple pneumothorax
   Show answer

   Answer: D. Simple pneumothorax

   Unilateral diminished breath sounds with stable vital signs fit a simple pneumothorax. A tension pneumothorax would add hypotension, distended neck veins, and worsening distress.

3. In a moving ambulance, it is hard to hear breath sounds in a patient with chest trauma. A useful additional way to detect a developing pneumothorax is to:

   1. A. Watch for unequal chest rise
   2. B. Rely only on the patient's skin color
   3. C. Wait for the hospital's chest X-ray
   4. D. Ask him to cough as hard as he can
   Show answer

   Answer: A. Watch for unequal chest rise

   Inspecting and palpating for asymmetric chest rise, along with SpO2, ETCO2, work of breathing, and vital sign trends, helps detect a worsening pneumothorax when auscultation is unreliable. Skin color is a late sign, waiting for imaging delays recognition, and forceful coughing gives no useful information.

4. A 68-year-old with severe COPD has sudden worsening shortness of breath and decreased breath sounds on one side after coughing. You should suspect:

   1. A. A simple COPD flare needing only nebs
   2. B. A secondary spontaneous pneumothorax
   3. C. Normal breath sounds for a COPD patient
   4. D. Pulmonary contusion from the cough
   Show answer

   Answer: B. A secondary spontaneous pneumothorax

   Patients with COPD can rupture fragile bullae, causing a secondary spontaneous pneumothorax, which is often poorly tolerated because their lung reserve is already low. Unilaterally decreased breath sounds with sudden worsening should not be dismissed as a flare. Coughing does not cause a contusion.

5. An open pneumothorax is:

   1. A. A torn bronchus that lets air into the mediastinum
   2. B. A lung laceration that lets air leak under the skin of the chest
   3. C. A chest wall wound that lets air enter the pleural space
   4. D. A pleural tear that traps air with every breath
   Show answer

   Answer: C. A chest wall wound that lets air enter the pleural space

   An open pneumothorax connects the pleural space to the outside, so air enters through the wound with each breath. A pleural tear that traps air is the one-way valve of a tension pneumothorax.

6. Air will preferentially enter through a chest wound rather than the trachea once the wound is at least about:

   1. A. One-tenth the diameter of the trachea
   2. B. Three times the diameter of the trachea
   3. C. Five times the diameter of the trachea
   4. D. Two-thirds the diameter of the trachea
   Show answer

   Answer: D. Two-thirds the diameter of the trachea

   Air follows the path of least resistance, so a wound about two-thirds the tracheal diameter or larger draws air in through the chest wall instead of the airway. Wounds much smaller than that rarely become sucking chest wounds.

7. A 30-year-old has a gunshot wound to the right chest that bubbles with each breath. Your first action is to:

   1. A. Pack the wound tightly with gauze
   2. B. Decompress the right chest with a needle
   3. C. Seal the wound with your gloved hand
   4. D. Apply a bulky dry dressing to it
   Show answer

   Answer: C. Seal the wound with your gloved hand

   Covering the wound immediately with a gloved hand stops air entry until a chest seal can be applied. A dry gauze dressing is not occlusive and lets air keep entering.

8. The advantage of a vented chest seal over a nonvented occlusive dressing is that it:

   1. A. Lets air enter while preventing its escape
   2. B. Lets air escape while preventing air entry
   3. C. Absorbs blood better than gauze does
   4. D. Adheres better to hairy or wet skin
   Show answer

   Answer: B. Lets air escape while preventing air entry

   A vented seal works as a one-way valve, so air under pressure can escape and a tension pneumothorax is less likely. A nonvented seal blocks air both ways, so trapped air can build up under it.

9. After you place a nonvented occlusive dressing on a chest wound, the patient becomes more dyspneic, with falling BP and distended neck veins. Your first action is to:

   1. A. Add a second dressing on top
   2. B. Turn up the oxygen flow rate
   3. C. Pack the wound with gauze
   4. D. Burp the dressing to release air
   Show answer

   Answer: D. Burp the dressing to release air

   Lifting one edge of the dressing lets the trapped air escape and relieves a developing tension pneumothorax; if this fails, needle decompression is next. Adding oxygen does not release the trapped air.

10. When you seal a penetrating chest wound, you should also:

    1. A. Check for and seal any exit wound
    2. B. Probe the wound to gauge its depth
    3. C. Irrigate the wound with saline
    4. D. Remove any object impaled in it
    Show answer

    Answer: A. Check for and seal any exit wound

    Bullets and blades can exit the back or side, and an unsealed exit wound keeps the chest open. Probing a wound causes more damage and adds nothing to field care.

11. In an awake, spontaneously breathing patient, a developing tension pneumothorax usually shows which findings first?

    1. A. Sudden hypotension with a normal SpO2
    2. B. Tracheal deviation before any distress
    3. C. Cardiac arrest without any warning
    4. D. Worsening distress and falling SpO2
    Show answer

    Answer: D. Worsening distress and falling SpO2

    In spontaneously breathing patients, tension typically progresses gradually, with increasing respiratory distress, tachycardia, and hypoxia before hypotension appears. Tracheal deviation is a late and unreliable sign. In ventilated patients, hypotension and arrest can occur abruptly.

12. A pneumothorax patient with no spinal concerns insists on sitting upright because he cannot breathe lying down. You should:

    1. A. Let him sit up in a position of comfort
    2. B. Lay him flat on his injured side firmly
    3. C. Lay him flat on his back with legs up
    4. D. Restrain him supine for monitoring
    Show answer

    Answer: A. Let him sit up in a position of comfort

    A patient with a chest injury and no spinal concern breathes best in the position he chooses, usually sitting up, which helps the diaphragm and chest wall work. Forcing him flat or restraining him increases distress and work of breathing.

13. Which is a late sign of tension pneumothorax?

    1. A. Diminished breath sounds on the injured side of the chest
    2. B. Tracheal deviation away from the injured side
    3. C. Tachycardia with anxiety and air hunger
    4. D. Tachypnea with sharp pain on inspiration
    Show answer

    Answer: B. Tracheal deviation away from the injured side

    Tracheal deviation appears only after pressure has shifted the mediastinum, often just before arrest, and it is seen low in the neck if at all. Diminished breath sounds and tachycardia appear earlier.

14. Jugular venous distention may be absent in a tension pneumothorax when the patient:

    1. A. Is lying supine on a backboard
    2. B. Is receiving supplemental oxygen
    3. C. Is also hypovolemic from blood loss
    4. D. Has a right-sided pneumothorax
    Show answer

    Answer: C. Is also hypovolemic from blood loss

    Neck veins can only distend if there is enough blood volume to fill them, so a bleeding patient may have flat veins despite tension. Lying supine tends to make neck veins more visible, not less.

15. A stable patient with a small traumatic pneumothorax is breathing on his own. Besides correcting hypoxia, supplemental oxygen may help because it:

    1. A. Seals the hole in the lung surface
    2. B. Pushes the air back into the lungs
    3. C. Speeds absorption of pleural air
    4. D. Prevents any need for a chest tube
    Show answer

    Answer: C. Speeds absorption of pleural air

    Breathing high concentrations of oxygen washes nitrogen out of the blood, increasing the gradient for absorbing the trapped pleural gas, so a small pneumothorax may resolve faster. Oxygen does not seal the leak, push air back into the lung, or guarantee that a chest tube will not be needed.

16. After a crash, a 40-year-old has absent breath sounds on the left, distended neck veins, and a BP of 72/50 mmHg. The prehospital treatment is:

    1. A. Needle decompression of the chest
    2. B. An occlusive dressing over the chest
    3. C. High-flow oxygen by nonrebreather
    4. D. A rapid infusion of 2 L of saline
    Show answer

    Answer: A. Needle decompression of the chest

    Needle decompression releases the trapped air and restores venous return. Oxygen and fluids support the patient but do nothing to relieve the pressure itself.

17. A patient with extensive subcutaneous emphysema of the chest and neck needs reassessment. This air can make it harder to:

    1. A. Measure his BP with an arm cuff
    2. B. Read the SpO2 at his fingertip
    3. C. Assess his capillary refill
    4. D. Hear lungs and feel landmarks
    Show answer

    Answer: D. Hear lungs and feel landmarks

    Air in the soft tissues muffles breath sounds and obscures the landmarks needed for needle decompression or a surgical airway, and its spread suggests an ongoing air leak (from lung, airway, or esophagus). It does not interfere with an arm blood pressure, a fingertip SpO2 reading, or capillary refill in the hands.

18. A 24-year-old with a stab wound to the chest has mildly decreased breath sounds on one side, normal vitals, and SpO2 of 96%. He wants a friend to drive him to the hospital. You should explain that:

    1. A. A small pneumothorax tends to heal on its own
    2. B. It can quickly become a tension pneumothorax
    3. C. Normal vital signs mean the lung is not hurt
    4. D. Stab wounds rarely enter the pleural space
    Show answer

    Answer: B. It can quickly become a tension pneumothorax

    A traumatic pneumothorax can enlarge and progress to tension physiology without warning, and a penetrating chest wound may also be bleeding into the chest. He needs monitored transport with the ability to decompress the chest. Normal vital signs do not exclude a significant injury, a pneumothorax from a stab wound cannot be counted on to resolve, and decreased breath sounds show this wound has already entered the pleural space.

19. During air medical transport, a pneumothorax tends to:

    1. A. Shrink as altitude increases
    2. B. Stay the same size at altitude
    3. C. Convert to a hemothorax
    4. D. Expand as altitude increases
    Show answer

    Answer: D. Expand as altitude increases

    By Boyle's law, gas expands as surrounding pressure falls, so a pneumothorax enlarges at altitude. This is why a small pneumothorax may need decompression before or during flight.

20. Compared with a spontaneously breathing patient, a tension pneumothorax in a patient receiving positive-pressure ventilation typically develops:

    1. A. More slowly, with gradual hypoxia
    2. B. At the same rate but without hypoxia
    3. C. More quickly, with abrupt hypotension
    4. D. Rarely, since pressure keeps the lung up
    Show answer

    Answer: C. More quickly, with abrupt hypotension

    Positive pressure forces air through the lung injury with every breath, so tension can build within minutes. The pressure does not hold the lung up against a leak; it drives more air into the pleural space.

21. A 28-year-old with a stab wound to the chest is alert and has no spinal concerns after you apply a vented chest seal. His BP is 124/80 mmHg. The best position for transport is:

    1. A. Semi-sitting position of comfort
    2. B. Prone with the wound side up
    3. C. Trendelenburg with legs raised
    4. D. Supine and flat on a backboard
    Show answer

    Answer: A. Semi-sitting position of comfort

    An alert, normotensive patient with no spinal concern usually breathes best sitting up. Lying flat or head-down pushes the abdominal contents against the diaphragm and makes breathing harder.

22. A 4-year-old struck by a car has rapidly worsening distress after a chest injury. Compared with adults, a tension pneumothorax in a young child:

    1. A. Shows tracheal deviation earlier
    2. B. Shifts the mediastinum more easily
    3. C. Causes hypotension before tachycardia
    4. D. Progresses more slowly than in adults
    Show answer

    Answer: B. Shifts the mediastinum more easily

    A child's mediastinum is more mobile, so a tension pneumothorax can compress the heart and great vessels and impair venous return quickly. Tracheal deviation is still unreliable and late, children hold their blood pressure until late, so tachycardia and distress come before hypotension, and progression is often faster, not slower.

23. You are treating a sucking chest wound and have no commercial chest seal. The best improvised dressing is:

    1. A. Plastic wrap or foil as an occlusive seal
    2. B. Dry gauze pads taped down on all sides
    3. C. A moist gauze pad held loosely in place over it
    4. D. A folded cravat tied around the chest
    Show answer

    Answer: A. Plastic wrap or foil as an occlusive seal

    Any airtight material such as plastic wrap or foil, taped over the wound, can serve as an occlusive seal. Gauze, wet or dry, lets air pass through and does not seal the wound.

24. An occlusive dressing on a sucking chest wound is ideally applied at the end of a forced exhalation because:

    1. A. The wound edges are farthest apart
    2. B. The patient's pain is at its lowest
    3. C. Less air remains in the pleural space
    4. D. The dressing sticks better to dry skin
    Show answer

    Answer: C. Less air remains in the pleural space

    Sealing at the end of exhalation traps the least possible air in the pleural space. Timing has no real effect on how well the dressing adheres.

25. A 22-year-old has sudden sharp left chest pain that began at rest, with mild dyspnea. His BP is 126/80 mmHg, his SpO2 is 95% on room air, and breath sounds are slightly diminished on the left. Your care should include:

    1. A. Needle decompression at the left 2nd intercostal space
    2. B. CPAP at 10 cm H2O to help re-expand the lung
    3. C. Assisted ventilation with a BVM at 12/min
    4. D. Position of comfort, monitoring, O2 if needed
    Show answer

    Answer: D. Position of comfort, monitoring, O2 if needed

    This is a stable, probably small spontaneous pneumothorax. He needs a position of comfort, oxygen only if he is hypoxic (target SpO2 about 94%), and close reassessment for signs of tension during transport. Needle decompression is reserved for tension with respiratory or circulatory compromise; in a stable patient it adds risk and can create a larger pneumothorax. CPAP and BVM ventilation are positive-pressure treatments that can push more air through the leak and convert a simple pneumothorax into a tension pneumothorax, and he is ventilating adequately on his own. (ATLS 10th ed., Ch. 4; PHTLS 10th ed., thoracic trauma.)