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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The client has a paralytic ileus is correct. Morphine can cause decreased gastrointestinal motility, which can exacerbate a paralytic ileus.
B. The client is experiencing a myocardial infarction is incorrect. Morphine is commonly used to manage pain and reduce myocardial oxygen demand during a myocardial infarction.
C. The client who has bronchitis pleurisy is incorrect. Morphine can be used for pain control in pleurisy, but it is not contraindicated.
D. The client who is 24 hr postoperative following hip arthroplasty is incorrect. Morphine is used for postoperative pain management.
Correct Answer is B
Explanation
A. Keeping the leg in a dependent position can increase swelling; the leg should be elevated to reduce swelling.
B. Applying ice to the affected area is recommended to reduce swelling and pain after arthroscopic knee surgery.
C. Active range of motion exercises might be recommended, but this depends on the surgeon’s instructions and typically starts after the initial recovery period.
D. Bedrest for 24 hours is not usually required; gentle movement and following specific rehabilitation protocols are encouraged.
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