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.
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Related Questions
Correct Answer is D
Explanation
A. A difference between the apical pulse rate and the radial pulse rate is more indicative of a pulse deficit, which is not specific to constrictive pericarditis.
B. A drop in systolic blood pressure by 20 mm Hg when changing positions describes orthostatic hypotension, not paradoxical blood pressure.
C. An increase in heart rate when moving from sitting to standing reflects orthostatic changes, not paradoxical blood pressure.
D. Paradoxical blood pressure refers to a decrease in systolic blood pressure of more than 10 mm Hg during inspiration, which can occur in constrictive pericarditis due to impaired filling of the heart during diastole.
Correct Answer is ["D","E"]
Explanation
A. Assessment of Lower Extremities
Edema is common in renal failure but not specific to transplant rejection.
B. Sodium Level
Sodium level changes can occur with various conditions but are not specific to transplant rejection.
C. Lung Sounds
Lung sounds are important for respiratory issues but not directly indicative of kidney transplant rejection.
D. Creatinine Level
Elevated creatinine indicates possible kidney dysfunction or rejection.
E. Assessment of Incision Site
Signs of infection or inflammation at the incision site could indicate transplant issues.
F. Bowel Sounds
Hypoactive bowel sounds are related to gastrointestinal issues, not directly to transplant rejection.
G. Blood Pressure
Elevated blood pressure can be a consequence of many conditions but is not specific for transplant rejection.
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