A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

Blockage of the ET tube by the client's tongue

Movement of the ET tube into the right main bronchus

Infection of the vocal cords

Passage of the ET tube into the esophagus

Answer and Explanation

The Correct Answer is B

A. Blockage of the ET tube by the client's tongue would not typically result in asymmetric chest wall expansion.
B. If the ET tube has moved into the right main bronchus, it will cause more air to enter the right lung and less to the left, leading to decreased left-sided chest wall expansion.
C. Infection of the vocal cords is not related to the absence of chest wall expansion.
D. Passage of the ET tube into the esophagus would lead to the absence of breath sounds in both lungs, not just the left side.

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

Explanation

A. Slurred speech can indicate increased ICP as it may affect neurological function.

B. Headache is a common symptom of increased ICP.

C. Pupillary changes can indicate increased ICP, affecting cranial nerve function.

D. Neck pain and stiffness are more associated with meningitis or other conditions, not specifically increased ICP.

E. Disorientation can be a sign of increased ICP affecting brain function.

A. Engage in repetitive tasks, even when joints are inflamed, to keep the joints mobile. B. Press water from a sponge rather than wringing it. C. Finish weekly household tasks within 1 or 2 days. D. Turn doorknobs using a clockwise motion.

Correct Answer is B

Explanation

A. Engage in repetitive tasks, even when joints are inflamed, to keep the joints mobile is not recommended; rest and joint protection are important during inflammation.

B. Press water from a sponge rather than wringing it is a good strategy to avoid straining the joints.

C. Finish weekly household tasks within 1 or 2 days may lead to increased stress on the joints; tasks should be spread out to avoid exacerbating symptoms.

D. Turn doorknobs using a clockwise motion does not have specific benefits for managing rheumatoid arthritis; using adaptive devices is generally recommended.

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A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

Nursing Test Bank

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