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 ["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
Correct Answer is B
Explanation
A. Check the tubing connections for leaks. is incorrect. Slow, steady bubbling in the suction control chamber is normal if suction is correctly set up.
B. Check the suction control outlet on the wall. is correct. If there is slow, steady bubbling, it may indicate that the suction control pressure needs adjustment.
C. Continue to monitor the client's respiratory status. is incorrect. While monitoring is always important, it does not address the issue of the bubbling in the suction control chamber.
D. Clamp the chest tube. is incorrect. Clamping the chest tube is not appropriate and can lead to complications.
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