A client in the emergency department presents with chest pain, diaphoresis, and ST-segment elevation on ECG. Which condition should the nurse suspect?

Choice A reason: Hemodialysis rapidly removes fluid and solutes, which can cause significant hemodynamic shifts, including hypotension, in unstable patients. It involves high blood flow rates and ultrafiltration, stressing the cardiovascular system. For a hemodynamically unstable patient with acute renal failure, hemodialysis is less suitable due to its potential to exacerbate hypotension and circulatory collapse.

Choice B reason: Peritoneal dialysis uses the peritoneal membrane for slow fluid and solute exchange, which is gentler on hemodynamics. However, it is less efficient for rapid correction of hypervolemia and hyperkalemia in acute renal failure. It also carries risks of peritonitis and is impractical in critically ill patients with abdominal trauma or instability.

Choice C reason: Continuous venovenous hemodialysis (CVVHD) is ideal for hemodynamically unstable patients. It provides slow, continuous fluid and solute removal, minimizing cardiovascular stress. CVVHD effectively manages hypervolemia and hyperkalemia in acute renal failure by maintaining steady-state clearance, reducing the risk of hypotension compared to intermittent hemodialysis, making it the best choice.

Choice D reason: Plasmapheresis removes plasma components, not fluid or electrolytes like potassium, and is used for conditions like autoimmune disorders, not acute renal failure. It does not address hypervolemia or hyperkalemia and can cause hemodynamic instability due to rapid plasma exchange, making it inappropriate for this patient’s needs.

Choice A reason: Esophageal intubation results in no chest wall expansion bilaterally, as air enters the stomach, not the lungs. The client’s unilateral absence of left-sided expansion suggests air is entering the right lung, indicating the tube is in the trachea but malpositioned, not in the esophagus, which would affect both sides.

Choice B reason: Vocal cord infection, or laryngitis, may cause hoarseness or airway swelling but does not cause unilateral chest wall expansion failure. This finding indicates a mechanical issue with ventilation distribution, such as tube malposition. Infection affects mucosal function, not lung expansion, making this an unlikely cause of the observed symptom.

Choice C reason: Movement of the endotracheal tube into the right main bronchus causes right-sided ventilation and left-sided collapse, resulting in absent left chest wall expansion. This malposition, common due to the right bronchus’s straighter anatomy, leads to unilateral ventilation, matching the client’s presentation and requiring urgent repositioning to restore bilateral lung function.

Choice D reason: Tongue blockage of the endotracheal tube is unlikely, as the tube is placed beyond the oral cavity. Even if obstructed, it would affect both lungs, not just the left. The unilateral absence of expansion points to tube malposition in the right bronchus, selectively ventilating one lung, not a tongue-related obstruction.