A nurse in the PACU is assessing a client who has an endotracheal tube (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

Infection of the vocal cords

Passage of the ET tube into the esophagus

Movement of the ET tube into the right main bronchus

Answer and Explanation

The Correct Answer is D

A. Blockage of the ET tube by the client's tongue: If the ET tube is blocked by the tongue, the nurse would expect difficulty breathing or noisy respirations, not asymmetric chest wall expansion. This issue would typically affect both sides of the chest, not just one side.

B. Infection of the vocal cords: Infection of the vocal cords can lead to hoarseness or difficulty with speech but would not cause asymmetric chest wall expansion. The physical sign of unequal chest expansion is more related to airway placement or obstruction.

C. Passage of the ET tube into the esophagus: If the ET tube were in the esophagus, it would obstruct airflow entirely, leading to no chest expansion on either side and no air exchange. The observed asymmetry suggests partial blockage or malposition of the ET tube.

D. Movement of the ET tube into the right main bronchus: If the ET tube has moved into the right main bronchus, it would primarily ventilate the right lung, leading to absent expansion on the left side. This occurs because the tube is no longer in the trachea but in a more lateral position, ventilating only the right lung.

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Correct Answer is A

Explanation

A. Defibrillation: Ventricular fibrillation (VF) is a life-threatening arrhythmia that requires immediate defibrillation to restore normal rhythm. The priority action in a pulseless, unresponsive, and apneic client is to deliver a shock to stop the erratic electrical activity and allow the heart to re-establish a normal rhythm.

B. Airway management: While airway management is crucial for any unresponsive client, it is not the immediate priority in ventricular fibrillation. The first step is to treat the arrhythmia with defibrillation, as the absence of a pulse and irregular rhythm are more immediately life-threatening.

C. Amiodarone administration: Amiodarone may be administered after defibrillation attempts if VF persists. However, defibrillation is the first-line treatment. Amiodarone is considered once initial resuscitation efforts are underway and if the rhythm does not convert.

D. Epinephrine administration: Epinephrine can be administered after defibrillation if needed. However, defibrillation remains the priority intervention for ventricular fibrillation. Epinephrine is usually given after the first shock and subsequent CPR.

A. Atrial Fibrillation (A-fib) B. Ventricular Fibrillation C. Ventricular Tachycardia D. Atrial Flutter (A-Flutter)

Correct Answer is B

Explanation

A. Atrial Fibrillation (A-fib): While Atrial Fibrillation is irregularly irregular and lacks discrete P waves, its QRS complexes are typically narrow and uniform, reflecting normal ventricular conduction. The QRS complexes in this strip are wide, bizarre, and highly irregular.

B. Ventricular Fibrillation: Ventricular fibrillation is characterized by rapid, chaotic electrical activity in the ventricles, resulting in no discernible P waves, QRS complexes, or T waves. The EKG appears as a disorganized, wavy line, indicating that the ventricles are merely quivering and not effectively pumping blood.

C. Ventricular Tachycardia: Ventricular tachycardia is typically a regular or slightly irregular rhythm with wide identifiable QRS complexes, and a rate usually between 100-250 bpm. While this rhythm is fast, it is completely chaotic and disorganized with no identifiable QRS complexes.

D. Atrial Flutter (A-Flutter): Atrial flutter is characterized by a "sawtooth" pattern of atrial activity (flutter waves) and typically a regular ventricular rhythm. This strip shows chaotic, disorganized ventricular activity, not organized flutter waves.

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A nurse in the PACU is assessing a client who has an endotracheal tube (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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?

Correct Answer is A

Explanation

You note the cardiac electrical rhythm below (see 6-second EKG strip). Which of the following would BEST describe the client's rhythm?

Correct Answer is B

Explanation

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