The client has experienced left-sided chest trauma 3 hours ago, including simple fractures of three ribs. The nurse now finds the client to have increased dyspnea, pulse oximetry of 96%, and tracheal deviation to the right. What is the nurse's interpretation of these findings?

Flail chest

Pulmonary contusion

Tension pneumothorax

Adult respiratory distress syndrome

Answer and Explanation

The Correct Answer is C

Rationale:
A. Flail chest is incorrect because flail chest is characterized by paradoxical chest wall movement during breathing due to multiple rib fractures. While the patient has rib fractures, the presence of tracheal deviation is not typical of flail chest and indicates a more urgent condition.

B. Pulmonary contusion is incorrect because a pulmonary contusion presents with dyspnea, hypoxemia, and sometimes hemoptysis, but tracheal deviation is not a feature. Contusions cause impaired gas exchange due to alveolar bleeding, not mechanical displacement of the mediastinum.

C. Tension pneumothorax is correct. The patient exhibits tracheal deviation to the right (away from the injured left side), which is a classic sign of tension pneumothorax. Other signs include dyspnea, tachypnea, hypotension, distended neck veins, and decreased breath sounds on the affected side. Tension pneumothorax is a life-threatening emergency caused by air entering the pleural space and compressing the lung and mediastinal structures, which requires immediate needle decompression or chest tube insertion.

D. Adult respiratory distress syndrome (ARDS) is incorrect because ARDS develops hours to days after a severe insult and presents with progressive hypoxemia and bilateral pulmonary infiltrates. It does not typically cause tracheal deviation.

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Correct Answer is ["B","C"]

Explanation

Rationale:

A. Nasogastric suctioning removes gastric contents, including hydrochloric acid. This loss of acid can lead to metabolic alkalosis, not respiratory acidosis, because it affects the bicarbonate-to-acid balance in the blood. It does not interfere with CO2 retention or the respiratory process, so it does not directly cause respiratory acidosis.

B. Sedatives, including benzodiazepines, barbiturates, or opioids, can depress the central respiratory center in the brainstem. When the respiratory drive is suppressed, the patient breathes more slowly or shallowly, resulting in hypoventilation. Hypoventilation leads to CO2 retention, which combines with water to form carbonic acid, lowering blood pH and causing respiratory acidosis. This is a common scenario in overdose situations, particularly in older adults or patients with pre-existing lung disease.

C. CNS depression can result from head trauma, stroke, tumors, or other neurologic disorders that impair the brain’s ability to regulate breathing. Like sedative overdose, CNS depression reduces respiratory drive, leading to inadequate alveolar ventilation, CO2 accumulation, and respiratory acidosis. This is why monitoring respiratory rate, depth, and ABGs is critical in patients with CNS compromise.

D. Diabetic ketoacidosis (DKA) causes metabolic acidosis due to the accumulation of ketone bodies, not respiratory acidosis. Patients with DKA usually hyperventilate (Kussmaul respirations) as a compensatory mechanism to blow off CO2 and partially correct the acidosis. Therefore, DKA predisposes to metabolic, not respiratory, acid-base disturbances.

E. Anxiety and fear typically lead to hyperventilation, in which the patient breathes rapidly and deeply. This causes excessive CO2 elimination, lowering PaCO2 and resulting in respiratory alkalosis, the opposite of respiratory acidosis.

A. document the presence of a large air leak. B. obtain and attach a new collection device. C. notify the health care provider of a possible pneumothorax. D. take no further action with the collection device.

Correct Answer is D

Explanation

Rationale:

A. Continuous bubbling in the suction-control chamber is normal when suction is applied; it does not indicate an air leak. Air leaks are assessed in the water-seal chamber, not the suction-control chamber.

B. Replacing the collection device is not necessary for normal suction-chamber bubbling. The current setup is functioning as intended.

C. Continuous bubbling in the suction-control chamber is expected when suction is applied. A pneumothorax is indicated by bubbling in the water-seal chamber or worsening respiratory status, not the suction chamber.

D. Continuous bubbling in the suction-control chamber of a chest tube collection system is expected when suction is applied. The nurse should monitor for changes in the water-seal chamber (e.g., intermittent bubbling that could indicate an air leak) and assess the patient’s respiratory status, but no immediate action is required for the suction chamber itself.

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The client has experienced left-sided chest trauma 3 hours ago, including simple fractures of three ribs. The nurse now finds the client to have increased dyspnea, pulse oximetry of 96%, and tracheal deviation to the right. What is the nurse's interpretation of these findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which factors may predispose the patient to respiratory acidosis? Select all that apply.

Correct Answer is ["B","C"]

Explanation

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to

Correct Answer is D

Explanation

Select all of the factors that may predispose the patient to respiratory acidosis. Select all that apply.

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An RN is observing a nursing student who is open suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene?

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