The nurse understands that PEEP is a form of increased pressure, and that when using high levels of PEEP the patient's lung can suffer barotrauma.
If the patient suffers barotrauma resulting in a left-sided pneumothorax, what would the expected assessment findings be?
Absence of lung sounds on the right side.
Absence of lung sounds or chest rise on the left side.
Hypertension and Bradypnea.
Lack of chest rise bilaterally.
The Correct Answer is B
Choice A rationale
The absence of lung sounds on the right side would indicate a problem in the right lung, such as a right-sided pneumothorax or severe atelectasis of the right lung. Given the scenario specifies a left-sided pneumothorax, the primary assessment findings would be localized to the affected (left) side, not the contralateral side.
Choice B rationale
A left-sided pneumothorax, characterized by air accumulating in the pleural space on the left side, will lead to collapse of the left lung. This collapse will result in an absence of breath sounds and diminished or absent chest rise on the affected (left) side due to the lung's inability to inflate and participate in ventilation.
Choice C rationale
Hypertension (elevated blood pressure) and bradypnea (slow respiratory rate) are not typical primary findings in an acute pneumothorax. While a pneumothorax can cause respiratory distress, it often leads to tachypnea (increased respiratory rate) as the body attempts to compensate for reduced lung function and potentially hypotension due to impaired venous return.
Choice D rationale
Lack of chest rise bilaterally would indicate a more generalized respiratory issue, such as severe bilateral atelectasis, bilateral mainstem bronchus obstruction, or a severe neurological impairment affecting respiratory drive. In a unilateral pneumothorax, the contralateral lung would typically still demonstrate some degree of chest rise, although it might be diminished. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Cyanosis, a bluish discoloration of the skin and mucous membranes, is a late and ominous sign of hypoxia. It becomes clinically apparent when there are approximately 5 grams per deciliter of desaturated hemoglobin. This indicates a significant reduction in oxygen saturation and severe tissue hypoxia, representing a decompensated physiological state.
Choice B rationale
Bradycardia, a slower than normal heart rate (normal range 60-100 beats per minute for adults), is typically a late sign of hypoxia, particularly in adults. Initially, the body often compensates for hypoxia with tachycardia to increase cardiac output and oxygen delivery. Profound and prolonged hypoxia can depress myocardial function, leading to bradycardia.
Choice C rationale
Hypotension, a low blood pressure (normal range systolic 90-120 mmHg, diastolic 60-80 mmHg), is generally considered a late sign of hypoxia. In the early stages, the sympathetic nervous system may initially increase blood pressure as a compensatory mechanism. However, prolonged or severe hypoxia can lead to myocardial depression and vasodilation, resulting in hypotension.
Choice D rationale
Agitation is an early neurological sign of hypoxia. As oxygen levels decrease, cerebral hypoxia affects brain function, leading to irritability, restlessness, and confusion. The brain is highly sensitive to oxygen deprivation, and these behavioral changes are often among the first indicators of inadequate oxygenation, preceding more overt physiological decompensation.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Daily sedation and weaning protocols, often termed "sedation vacations," reduce the duration of mechanical ventilation by allowing for spontaneous breathing trials. Decreased ventilation duration minimizes the risk of VAP by reducing exposure to invasive tubes and promoting earlier extubation and mobility.
Choice B rationale
Oral care with Chlorhexidine (CHG) significantly reduces the bacterial load in the oropharynx. This decreases the aspiration of pathogenic microorganisms into the lungs, which is a primary pathway for the development of ventilator-associated pneumonia (VAP), thereby disrupting biofilm formation.
Choice C rationale
Suctioning on a frequent schedule can actually increase the risk of VAP by introducing bacteria into the lower respiratory tract. Suctioning should only be performed as needed based on patient assessment, such as visible secretions or adventitious breath sounds, to minimize contamination.
Choice D rationale
Elevating the head of the bed (HOB) to 30 degrees or more helps prevent aspiration of oropharyngeal secretions and gastric contents into the lungs. This reduces the risk of VAP by minimizing the entry of bacteria from the upper airway and gastrointestinal tract into the sterile lower respiratory tract.
Choice E rationale
Hand hygiene is paramount in preventing healthcare-associated infections, including VAP. Proper handwashing or alcohol-based hand rub use before and after patient contact, and especially before manipulating the ventilator circuit, reduces the transmission of pathogens to the patient.
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