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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A difference between the apical pulse rate and the radial pulse rate is more indicative of a pulse deficit, which is not specific to constrictive pericarditis.
B. A drop in systolic blood pressure by 20 mm Hg when changing positions describes orthostatic hypotension, not paradoxical blood pressure.
C. An increase in heart rate when moving from sitting to standing reflects orthostatic changes, not paradoxical blood pressure.
D. Paradoxical blood pressure refers to a decrease in systolic blood pressure of more than 10 mm Hg during inspiration, which can occur in constrictive pericarditis due to impaired filling of the heart during diastole.
Correct Answer is ["B","D","E"]
Explanation
A. Hypotension is not typically associated with ESRD; hypertension is more common due to fluid retention and alterations in renin-angiotensin system.
B. Bone pain is common in ESRD due to disturbances in calcium and phosphate metabolism, leading to renal osteodystrophy.
C. Bradypnea is not an expected finding; however, patients may exhibit Kussmaul respirations if they have metabolic acidosis.
D. Slurred speech is a typical finding in ESRD.
E. Pruritus is a common symptom in ESRD due to the buildup of uremic toxins and alterations in calcium and phosphate metabolism.
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