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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Granulocytes are typically not decreased in ITP; they are more relevant for infections or bone marrow conditions.
B. RBC levels are not typically affected in ITP; the primary issue is with platelet counts.
C. WBC levels are generally normal in ITP, though they can vary in other conditions.
D. Platelets are expected to be decreased in ITP, which is characterized by an immune-mediated destruction of platelets.
Correct Answer is ["24"]
Explanation
- First, determine the concentration of the heparin solution. In this case, it's 25,000 units in 500 mL, which means there are 50 units per mL.
- Next, calculate the required rate to deliver 1,200 units per hour. Since the concentration is 50 units per mL, divide 1,200 units by 50 units/mL to find the required mL per hour.
- The calculation will be 1,200 units/hr ÷ 50 units/mL = 24 mL/hr.
- Since the question asks to round to the nearest tenth or whole number, and the result is a whole number, the IV pump should be set to deliver 24.0 mL/hr.
Answer =24
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