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 B

Explanation

A. Bradypnea, or abnormally slow breathing, is not typically associated with hypoxia. Hypoxia usually triggers an increase in respiratory rate (tachypnea) as the body attempts to take in more oxygen to meet its needs.
B. Cyanosis, a bluish discoloration of the skin and mucous membranes, is a key sign of hypoxia. It occurs when there is insufficient oxygen in the blood, leading to a darker color of deoxygenated hemoglobin. Cyanosis is most commonly observed in the lips, fingertips, and toes.
C. Pallor, or paleness of the skin, can occur in various conditions but is not specific to hypoxia. It is more commonly associated with anemia or shock rather than low oxygen levels in the blood.
D. Bradycardia, or a slower-than-normal heart rate, is not typically a manifestation of hypoxia. Instead, hypoxia often causes tachycardia as the body attempts to increase oxygen delivery to tissues by pumping blood more quickly.

A. Expiratory wheeze B. Rhonchi C. Pleural friction rub D. Fine rales

Correct Answer is A

Explanation

A. Expiratory wheeze: Wheezing, particularly on expiration, is a characteristic finding during an acute asthma exacerbation. It occurs due to the narrowing of the airways and turbulent airflow.

B. Rhonchi: Rhonchi are low-pitched, rattling sounds often caused by secretions in larger airways, not typically associated with asthma exacerbations.

C. Pleural friction rub: A pleural friction rub is a grating sound heard when the pleurae are inflamed, often seen in conditions like pleuritis, not asthma.

D. Fine rales: Fine rales, or crackles, are associated with fluid in the alveoli, often found in conditions like pneumonia or heart failure, rather than asthma

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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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