A nurse is collecting data for 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

Answer and Explanation

The Correct Answer is C

A. Respiratory alkalosis: Respiratory alkalosis is generally associated with hyperventilation and is not directly caused by tension pneumothorax. In tension pneumothorax, the primary issues are related to pressure changes within the thoracic cavity, not respiratory alkalosis.

B. Increased venous return: In tension pneumothorax, venous return is actually decreased due to the increased intrathoracic pressure compressing the great vessels, which impedes blood flow back to the heart.

C. Decreased cardiac output: Tension pneumothorax causes a significant increase in intrathoracic pressure, leading to compression of the heart and great vessels, which results in decreased venous return and ultimately decreased cardiac output. This is a critical and life-threatening consequence of tension pneumothorax.

D. Dilated ventricles: Dilated ventricles are more commonly seen in chronic heart conditions such as heart failure, rather than in acute tension pneumothorax. Tension pneumothorax typically results in reduced ventricular filling rather than dilation.

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Correct Answer is D

Explanation

A. The "Choice of Analgesia and Sedation" component of the ABCDEF assessment tool focuses on selecting appropriate pain relief and sedation strategies for the patient but does not directly relate to the weaning process.
B. "Assess, Prevent, and Manage Pain" involves ensuring the patient is comfortable and free from pain, which is important but not specifically related to weaning from the ventilator.
C. "Delirium: Assess, Prevent, and Manage" addresses the cognitive status of the patient, particularly the prevention and management of delirium, which is a critical aspect of care but not directly related to ventilator weaning.
D. "Breathing: Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)" directly involves the weaning process, as it includes assessing the patient's ability to breathe independently by reducing or removing sedation (SAT) and evaluating their capacity for spontaneous breathing (SBT).

A. Avoid vitamin supplements during therapy. B. Drink alcohol in small amounts only. C. Report yellow eyes or skin immediately. D. Increase intake of Swiss or aged cheeses.

Correct Answer is C

Explanation

A. Avoid vitamin supplements during therapy: This is not generally advised for isoniazid therapy. In fact, vitamin B6 supplements are often recommended to prevent peripheral neuropathy caused by isoniazid.

B. Drink alcohol in small amounts only: Alcohol can increase the risk of liver toxicity when taking isoniazid. It is typically advised to avoid alcohol altogether during treatment.

C. Report yellow eyes or skin immediately: Isoniazid can cause liver toxicity, which can lead to jaundice (yellowing of the eyes and skin). This is a serious side effect and should be reported immediately to prevent further liver damage.

D. Increase intake of Swiss or aged cheeses: This recommendation is not related to isoniazid therapy. Aged cheeses are more relevant to patients on monoamine oxidase inhibitors (MAOIs) due to tyramine content.

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A nurse is collecting data for a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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