A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?
Respiratory alkalosis
Increased venous return
Decreased cardiac output
Dilated ventricles
The Correct Answer is C
Choice A Reason:
Respiratory alkalosis is incorrect. Tension pneumothorax typically leads to respiratory distress and hypoxemia rather than respiratory alkalosis. The respiratory alkalosis may occur initially due to hyperventilation in response to hypoxemia but would not be directly related to tracheal deviation.
Choice B Reason:
Increased venous return is incorrect. Tension pneumothorax actually leads to decreased venous return due to compression of the great vessels in the thorax, particularly the superior vena cava and the inferior vena cava. This compression results from the increased pressure within the thorax, which impedes blood flow back to the heart.
Choice C Reason:
Decreased cardiac output is incorrect. Tension pneumothorax can indeed lead to decreased cardiac output due to compression of the heart and the great vessels by the accumulating air in the pleural space. This compression decreases venous return and impairs cardiac function.
Choice D Reason:
Dilated ventricles is incorrect. As mentioned earlier, tension pneumothorax can lead to compression of the heart, including the ventricles. This compression can cause dilatation of the ventricles, particularly the right ventricle, due to increased afterload and decreased venous return.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Decreased blood pressure is correct. Decreased blood pressure (hypotension) is the priority finding to monitor for because it is indicative of a severe allergic reaction known as anaphylaxis. Anaphylaxis is a potentially life-threatening condition that can lead to shock, organ failure, and death if not promptly treated. Hypotension in the context of an allergic reaction suggests widespread vasodilation and increased vascular permeability, resulting in a decrease in blood pressure.
Choice B Reason:
Stomach pain is incorrect. Stomach pain may indicate gastrointestinal distress or adverse effects of the antibiotic, but it is not typically as immediately life-threatening as decreased blood pressure in the context of anaphylaxis. While abdominal pain should not be ignored, it is not the priority finding when assessing for signs of anaphylaxis.
Choice C Reason:
Urticaria is incorrect. Urticaria, also known as hives, is a common allergic reaction characterized by raised, itchy welts on the skin. While urticaria can be uncomfortable and distressing, it is not immediately life-threatening. However, urticaria may be a precursor to more severe allergic reactions, such as anaphylaxis, so it is still important to monitor closely.
Choice D Reason:
Lightheadedness is incorrect. Lightheadedness may occur as a result of hypotension in the context of anaphylaxis, but it is not as critical as directly monitoring blood pressure. Lightheadedness may also be caused by other factors, such as anxiety or dehydration, and may not always indicate a severe allergic reaction. While it is important to assess for lightheadedness and monitor the client's overall condition, it is not the priority finding compared to decreased blood pressure.
Correct Answer is C
Explanation
Choice A Reason:
Previous stroke is not directly associated with an increased risk of status asthmaticus. While individuals with certain medical conditions, such as neurological disorders, may have an increased risk of complications from severe asthma exacerbations, a previous stroke alone is not a recognized risk factor for status asthmaticus.
Choice B Reason:
Irritants and hypersensitivity to medications, may trigger asthma exacerbations, but they are not specific risk factors for status asthmaticus. Asthma exacerbations triggered by irritants or medications can typically be managed with appropriate treatment measures and do not necessarily lead to status asthmaticus.
Choice C Reason:
Previous intubation due to status asthmaticus episode is correct. Status asthmaticus is a severe and life-threatening asthma exacerbation that is unresponsive to standard treatment measures such as bronchodilators and corticosteroids. It is characterized by prolonged and severe bronchospasm, airway inflammation, and respiratory distress.
Choice D Reason:
Bronchial pneumonia is not a known risk factor for status asthmaticus. Bronchial pneumonia, or pneumonia affecting the bronchi and lungs, is a separate respiratory condition caused by bacterial, viral, or fungal infections. While pneumonia can exacerbate asthma symptoms in individuals with asthma, it is not specifically associated with an increased risk of status asthmaticus.
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