The finding of normal breath sounds on the right side of the chest and decreased breath sounds on the left side of the chest in the newly intubated patient is probably due to a

gastric intubation

right mainstem intubation

right pneumothorax

left pneumothorax

Answer and Explanation

The Correct Answer is B

Rationale:

A. If the endotracheal tube is mistakenly placed in the stomach, there would be no breath sounds bilaterally, absent chest rise, and possible abdominal distention. Normal breath sounds on the right rule out gastric intubation.

B. If the endotracheal tube is advanced too far, it can enter the right main bronchus, which is wider, shorter, and more vertical than the left. This results in ventilation of only the right lung, producing normal breath sounds on the right and decreased or absent breath sounds on the left. This is a common complication of intubation and requires immediate repositioning of the tube.

C. A pneumothorax on the right side would cause absent or decreased breath sounds on the right, not the left. This is inconsistent with the finding of decreased breath sounds on the left.

D. A pneumothorax on the left side could decrease breath sounds on the left; however, in the context of a newly intubated patient, the more likely cause of unilateral decreased breath sounds is malposition of the tube in the right mainstem bronchus, especially if this is an acute finding immediately after intubation.

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Correct Answer is D

Explanation

Rationale:

A. Metabolic acidosis results from bicarbonate loss or acid accumulation (e.g., diabetic ketoacidosis, renal failure, diarrhea). It is unrelated to ventilation. Hyperventilation from tachypnea does not cause metabolic acid-base changes.

B. Metabolic alkalosis occurs due to excess bicarbonate or acid loss (e.g., vomiting, diuretics). Increased ventilation does not affect bicarbonate levels directly, so tachypnea does not cause metabolic alkalosis.

C. Respiratory acidosis occurs when there is hypoventilation, causing CO2 retention. This patient is hyperventilating, which would lower CO2 rather than raise it, so respiratory acidosis will not occur.

D. Tachypnea combined with the ventilator in assist/control mode leads to excessive removal of CO2, lowering PaCO2. This produces respiratory alkalosis, a common complication when a patient breathes rapidly above the ventilator set rate.

A. Document that the chest drainage system is operating as it is intended. B. Encourage the patient to do deep breathing and coughing exercises. C. Inform the physician promptly that there is an imminent leak in the drainage system. D. Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes.

Correct Answer is A

Explanation

Rationale:

A. The tidaling of fluid in a chest tube water-seal chamber, which rises and falls with respiration, is a normal and expected finding. It indicates that the chest tube is patent and that intrathoracic pressure changes are being transmitted to the drainage system. This confirms proper function, and the nurse should document the finding.

B. While deep breathing and coughing exercises are generally encouraged post-CABG to prevent atelectasis and improve lung expansion, they are not directly indicated in response to normal tidaling. This action is supportive care but does not address the assessment finding itself.

C. A leak in the system would be indicated by continuous bubbling in the water-seal chamber, not by normal tidaling. Tidaling is expected and does not signify a leak. Informing the physician is unnecessary unless other abnormal findings occur, such as sudden cessation of tidaling or excessive bubbling.

D. Manipulating the chest tube in this manner is unsafe and unnecessary for normal tidaling. Repositioning should only be considered if the tube is malfunctioning or dislodged, which is not indicated here.

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The finding of normal breath sounds on the right side of the chest and decreased breath sounds on the left side of the chest in the newly intubated patient is probably due to a

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is assessing a patient who has a chest tube in place post CABG. The nurse observes that the drainage in the tubing rises and falls in rhythm with the patient's respirations. How should the nurse best respond to this assessment finding?

Correct Answer is A

Explanation

The nurse would explain that emergency treatment of a tension pneumothorax requires

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