A nurse in the postanesthesia care unit is assessing a patient who has an endotracheal tube in place and observes the absence of left-sided chest wall expansion upon respiration.
Which of the following complications should the nurse suspect?
Passage of the ET tube into the esophagus.
Movement of the ET tube into the right main bronchus.
Infection of the vocal cords.
Blockage of the ET tube by the patient's tongue.
The Correct Answer is B
Choice A rationale
If the endotracheal tube were in the esophagus, there would be no chest wall expansion on either side, and breath sounds would be absent. Instead, abdominal distention would be observed as air enters the stomach. The absence of chest wall expansion on only one side indicates a problem within the respiratory tract, not an esophageal intubation.
Choice B rationale
The right main bronchus is wider, shorter, and more vertical than the left, making it more likely for an endotracheal tube to be advanced too far and enter this bronchus. When the tube is lodged in the right main bronchus, the left lung is not ventilated, leading to the absence of breath sounds and chest wall expansion on the left side, as observed.
Choice C rationale
Vocal cord infection would cause symptoms such as hoarseness, pain, and potentially swelling. It does not typically lead to the absence of unilateral chest wall expansion. The absence of left-sided chest wall expansion is a mechanical ventilation issue related to the tube's position, not an infectious process of the larynx.
Choice D rationale
A blockage of the endotracheal tube by the patient's tongue is anatomically impossible. The endotracheal tube is designed to bypass the oral cavity and extend past the tongue into the trachea. While the tube could become occluded by secretions or kinking, the tongue is not a source of obstruction for an properly placed endotracheal tube.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Acknowledging the frightening nature of the illness is a crucial therapeutic communication technique. By validating the patient's feelings of fear and anxiety, the nurse establishes trust and rapport. This approach shows empathy and helps the patient feel understood, which can reduce psychological distress. It also provides a foundation for the patient to be more receptive to subsequent nursing interventions and education.
Choice B rationale
Providing simple, clear explanations of what is happening helps to demystify the situation and reduce the patient's anxiety. When a person is anxious, their cognitive processing can be impaired, making it difficult to comprehend complex information. Short, concise explanations about the cause of their symptoms and the purpose of interventions can help the patient feel more in control and less overwhelmed, thereby alleviating some of their fear.
Choice C rationale
Requesting a prescription for antianxiety medications is not the most appropriate immediate action. While medications may eventually be necessary, the initial nursing actions should focus on non-pharmacological interventions. These include therapeutic communication and supportive presence. Pharmacological interventions are typically reserved for situations where non-pharmacological methods are insufficient or the anxiety is severe enough to cause physiological instability.
Choice D rationale
Staying with the patient and speaking in a quiet, calm voice is a primary nursing action for an anxious patient. A calm, reassuring presence can help to de-escalate the patient's anxiety by providing a sense of security and support. The nurse's calm demeanor can also model appropriate emotional regulation for the patient, which can help to reduce their physiological and psychological distress. This action is simple, immediate, and highly effective.
Correct Answer is ["5"]
Explanation
The patient has an order for heparin 100 units over one hour. Heparin from the pharmacy comes as 10,000 units in 500 ml. The nurse should set the pump to deliver how many ml/hr?.
Step 1: Calculate the concentration of the heparin solution. 10,000 units ÷ 500 mL = 20 units/mL.
Step 2: Determine the volume of solution required to deliver 100 units. 100 units ÷ (20 units/mL) = 5 mL.
Step 3: The infusion is to be delivered over one hour. 5 mL ÷ 1 hour = 5 mL/hr. The nurse should set the pump to deliver 5 mL/hr.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.