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":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

Administer an analgesic: Essential. The client is experiencing sudden, sharp chest pain and appears anxious, which indicates the need for pain management.

Initiate a weight-based continuous heparin infusion: Non-essential. This intervention is related to anticoagulation management and is not indicated for the immediate management of a pneumothorax or pain.

Initiate supplemental oxygen: Essential. The client has a low pulse oximetry reading of 85%, indicating a need for supplemental oxygen to improve oxygenation.

Prepare client for a chest tube insertion: Essential. The chest x-ray shows a right upper lobe pneumothorax, and preparing for chest tube insertion is crucial for managing this condition.

Insert an indwelling urinary catheter: Non-essential. There is no indication from the client's current condition that an indwelling urinary catheter is required.

Correct Answer is ["24"]

Explanation

- First, determine the concentration of the heparin solution. In this case, it's 25,000 units in 500 mL, which means there are 50 units per mL.

- Next, calculate the required rate to deliver 1,200 units per hour. Since the concentration is 50 units per mL, divide 1,200 units by 50 units/mL to find the required mL per hour.

- The calculation will be 1,200 units/hr ÷ 50 units/mL = 24 mL/hr.

- Since the question asks to round to the nearest tenth or whole number, and the result is a whole number, the IV pump should be set to deliver 24.0 mL/hr.

Answer =24

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits For each potential nursing action, click to specify if the action is essential, non-essential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

Correct Answer is ["24"]

Explanation

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