Chest X-Ray for Nurses (2025): ABCDE Interpretation with Examples

Most chest X-rays look busy until you apply a simple, repeatable checklist. This guide gives you a bedside-friendly ABCDE method, common red flags, a lines & tubes check, and mini-cases with answers—so you can choose two actions that change physiology now and two parameters that prove it worked (the exact NGN habit we teach at GoodNurse).

For perfusion/oxygenation context, keep ABG Interpretation Made Simple (2025) open. Tie radiographic findings to biomarkers with Cardiac Markers (2025): Troponin & BNP and to gas exchange with Lactate in Sepsis (2025).

Table of Contents

• The ABCDE Method (Floor Version)
• Quality Check Before You Read
• Lines & Tubes: Fast Placement Audit
• Common Patterns: What You’ll Actually See
• Red Flags & First Actions
• Mini Practice Cases (with Answers)
• FAQs
• Further Reading

The ABCDE Method (Floor Version)

Use the same order every time. It’s fast, NGN-friendly, and works even when the film quality isn’t perfect.

A — Airway & Mediastinum

• Trachea midline? Any deviation (tension pneumothorax, large effusion, mass)?
• Carina visible? Mainstem intubation risk if ETT is too deep.

B — Breathing (Lungs & Pleura)

• Compare right/left lung fields for asymmetry, interstitial markings, consolidation, atelectasis, pneumothorax.
• Look for pleural lines, costophrenic angle blunting (effusions).

C — Circulation (Cardiac silhouette & vessels)

• Cardiac size (rough guide: cardiothoracic ratio on PA view).
• Pulmonary vasculature: cephalization, Kerley B lines, perihilar “bat-wing” edema patterns.

D — Diaphragm & Below

• Diaphragm domes, sharp costophrenic angles, free air under diaphragm (perforation).
• Gastric bubble on the left; herniation vs elevated hemidiaphragm.

E — Everything else (Bones, soft tissues, devices)

• Ribs, clavicles, scapulae for fractures or lytic lesions.
• Soft-tissue emphysema, subcutaneous air; device location (lines, tubes, pacers).

Quality Check Before You Read

• Projection: PA vs AP (AP enlarges the heart—don’t over-call cardiomegaly).
• Rotation: Medial clavicle heads equidistant from spinous processes.
• Inspiration: ~10 posterior ribs on a good inspiratory film.
• Penetration: Spine just visible through the heart—not too dark, not too light.
• Timing: Compare to previous film and clinical status (are we getting better or worse?).

Lines & Tubes: Fast Placement Audit

• Endotracheal tube (ETT): Tip ~3–5 cm above carina (varies with neck flexion/extension).
• Nasogastric/OG tube: Tip in stomach beyond the diaphragm; no coiling in esophagus.
• Central line: Tip in lower SVC near cavoatrial junction (not in the right atrium).
• Chest tube: Side holes should be within the thoracic cavity.
• Pacemaker/ICD: Leads coursing to RA/RV appropriately.
• A-line (radial/femoral) won’t be on CXR but chest lines often accompany a-line care—pair with Arterial Lines & MAP for accuracy checks.

Cross-training references: ABG Interpretation (2025) for gas exchange, and Coagulation Studies (2025) when procedures or bleeding risk are in play.

Common Patterns: What You’ll Actually See

1) Lobar consolidation (pneumonia)

• Clues: Dense opacity with air bronchograms; often lobar boundaries.
• Actions: Oxygen to target; support work of breathing; expect cultures/antibiotics per order.
• Parameters: SpO₂, RR/WOB, temperature, symptom trajectory.
• Practice links: NGN Med-Surg Cases for integrated scenarios.

2) Pulmonary edema (cardiogenic)

• Clues: Perihilar “bat-wing” opacities, Kerley B lines, pleural effusions, enlarged heart (PA view).
• Actions: Oxygen; position upright; anticipate diuresis/afterload reduction per orders; monitor perfusion.
• Parameters: SpO₂, MAP, UOP, dyspnea relief.
• Tie to biomarkers: Cardiac Markers.

3) Atelectasis

• Clues: Volume loss, tracheal deviation toward the lesion, diaphragmatic elevation, linear “plate-like” opacities.
• Actions: Incentive spirometry, mobilization, pain control, suctioning as ordered.
• Parameters: SpO₂, RR/WOB, auscultation improvement.

4) Pleural effusion

• Clues: Meniscus sign, blunted costophrenic angles; large effusions can shift mediastinum.
• Actions: Oxygen to target; elevate HOB; anticipate drainage/diuresis per plan; monitor hemodynamics.
• Parameters: SpO₂, MAP, dyspnea, symptom relief.

5) Pneumothorax (PTX)

• Clues: Visible pleural line with no markings beyond; tension PTX may shift trachea away and flatten hemidiaphragm.
• Actions: If unstable, prepare for emergent decompression per algorithm; oxygen; monitor closely.
• Parameters: SpO₂, RR/WOB, MAP, symptom relief.

6) COPD hyperinflation

• Clues: Flattened diaphragms, increased retrosternal airspace, barrel chest appearance.
• Actions: Oxygen to target; bronchodilator and steroid protocols per orders; watch for air trapping/fatigue.
• Parameters: SpO₂, RR/WOB, ABG trajectory.

7) Lines/tubes malposition

• Clues: ETT mainstem, NG coiled, central line too high/low.
• Actions: Notify and prepare for repositioning; keep client safe (oxygenation first).
• Parameters: SpO₂, breath sounds symmetry, post-adjustment film if ordered.

Red Flags & First Actions

• Tracheal deviation + hypotension + unilateral lucency → treat as tension PTX risk: oxygen, rapid escalation for decompression.
• Massive white-out hemithorax → think large effusion or mainstem intubation with atelectasis; assess breath sounds and tube depth.
• Device malposition (ETT, NG, central line) → correct placement promptly to avoid harm.
• Sudden airspace changes with fever → pneumonia vs aspiration; support oxygenation and follow diagnostic pathway.

For linking radiology to labs and decisions, keep CBC & CMP (2025) handy, and ensure rhythm/hemodynamics are stable with EKG Basics (2025).

Mini Practice Cases (with Answers)

Case 1 — The right mainstem

• Stem: Post-intubation CXR: ETT ~1 cm above carina; right lung hyperinflated; left lung looks atelectatic; SpO₂ drifting down.
• Question: Best action pair?
• Answer: Withdraw ETT slightly per order, re-assess breath sounds and SpO₂; repeat film if ordered.
• Rationale: Mainstem intubation—oxygenation risk. Parameters: SpO₂, RR/WOB, symmetric breath sounds.

Case 2 — New unilateral opacity post-op

• Stem: Day 1 post-op; linear basilar opacities and mild elevation of right hemidiaphragm.
• Question: Priority?
• Answer: Incentive spirometry, mobilization, analgesia optimization.
• Rationale: Post-op atelectasis. Parameters: SpO₂, RR/WOB, auscultation.

Case 3 — Bat-wing pattern with orthopnea

• Stem: Dyspnea, orthopnea; perihilar opacities and small effusions; mild cardiomegaly on PA film.
• Question: First actions?
• Answer: Oxygen, upright positioning; anticipate diuresis per orders; monitor UOP and MAP.
• Rationale: Likely cardiogenic edema. Parameters: SpO₂, MAP, UOP, dyspnea relief.

Case 4 — Suspected PTX after line placement

• Stem: Central line placed; client pleuritic pain; CXR shows pleural line with no distal markings.
• Question: Nursing priorities?
• Answer: Oxygen, notify provider, prepare for decompression if unstable; continuous monitoring.
• Rationale: Iatrogenic pneumothorax risk. Parameters: SpO₂, RR/WOB, MAP.

Case 5 — Large effusion with shift

• Stem: Dyspnea, dullness to percussion; white-out with mediastinal shift.
• Question: Best action?
• Answer: Oxygen, elevate HOB; anticipate drainage per plan; monitor hemodynamics.
• Rationale: Large effusion impairing ventilation. Parameters: SpO₂, MAP, symptom relief.

FAQs

Do I diagnose from an AP portable?
No—AP enlarges the heart and can distort anatomy. Use it for trend + safety checks and confirm on better imaging when feasible.

How do I avoid over-calling pneumonia?
Pair the film with fever, WBC, sputum, and auscultation; compare to prior films. Atelectasis and edema can mimic consolidation.

What proves my intervention worked?
Choose SpO₂, RR/WOB, and MAP/UOP (if perfusion issues) as immediate parameters; imaging changes lag behind.

Further Reading