A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

Blockage of the ET tube by the client's tongue

Movement of the ET tube into the right main bronchus

Infection of the vocal cords

Passage of the ET tube into the esophagus

Answer and Explanation

The Correct Answer is B

A. Blockage of the ET tube by the client's tongue would not typically result in asymmetric chest wall expansion.
B. If the ET tube has moved into the right main bronchus, it will cause more air to enter the right lung and less to the left, leading to decreased left-sided chest wall expansion.
C. Infection of the vocal cords is not related to the absence of chest wall expansion.
D. Passage of the ET tube into the esophagus would lead to the absence of breath sounds in both lungs, not just the left side.

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Correct Answer is ["B","C","E"]

Explanation

A. Increase in hematocrit is not expected in fluid overload; it generally decreases due to dilution of blood components.

B. Increased respiratory rate can occur as the body tries to compensate for fluid overload, which may affect lung function and cause respiratory distress.

C. Increased blood pressure is a common finding in fluid overload due to increased blood volume in the circulatory system.

D. Increased temperature is not a typical finding in fluid overload; it might be associated with infection or inflammation instead.

E. Increased heart rate can occur as the body compensates for increased blood volume and higher blood pressure.

A. Obtain intravenous access B. Thoracentesis C. Pulmonary Function Tests (PFTS) D. Prepare for insertion of a chest tube. E. Obtain ABGS F. Computed tomography (CT) of the chest

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Obtain intravenous access: Anticipated: Essential for administering medications, fluids, and potential emergency treatments.
Thoracentesis: Non-essential: Typically used for pleural effusions, not primary treatment for pneumothorax; chest tube insertion is the main treatment.
Pulmonary Function Tests (PFTs): Non-essential: Useful for diagnosing chronic respiratory conditions but not a primary intervention for pneumothorax.
Prepare for insertion of a chest tube: Anticipated: A chest tube is often necessary to re-expand the lung and treat a significant pneumothorax.
Obtain ABGs: Anticipated: Important for assessing the client’s oxygenation and acid-base balance due to respiratory distress.
Computed tomography (CT) of the chest: Anticipated: CT can be used to diagnose the extent of the pneumothorax and guide treatment.

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A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

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