A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect?
Lethargy
Bradycardia
Intercostal retractions
Bradypnea
The Correct Answer is C
Intercostal retractions, or the inward movement of the chest wall between the ribs, are a sign of respiratory distress and hypoxia. They indicate increased work of breathing and reduced lung expansion, which are common in clients who have postoperative atelectasis. Atelectasis is a collapse of alveoli in a part of the lung, which impairs gas exchange and oxygenation.
a) Lethargy, or a state of reduced mental alertness and energy, is not a typical manifestation of hypoxia. It can be caused by other factors, such as pain, medication, infection, or electrolyte imbalance. Hypoxia usually causes restlessness, anxiety, or confusion.
b) Bradycardia, or a slow heart rate, is not a typical manifestation of hypoxia. It can be caused by other factors, such as medication, vagal stimulation, or heart block. Hypoxia usually causes tachycardia, or a fast heart rate, as the body tries to compensate for the low oxygen level.
d) Bradypnea, or a slow respiratory rate, is not a typical manifestation of hypoxia. It can be caused by other factors, such as medication, brain injury, or metabolic alkalosis. Hypoxia usually causes tachypnea, or a fast respiratory rate, as the body tries to increase oxygen intake and carbon dioxide elimination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer: D. Cheyne-Stokes respirations
Rationale:
A) Stridor: Stridor is a high-pitched, wheezing sound resulting from disrupted airflow in the upper airway. It is not characterized by alternating periods of hyperventilation and apnea, making this choice incorrect.
B) Kussmaul respirations: Kussmaul respirations are deep, labored breaths typically associated with metabolic acidosis, such as diabetic ketoacidosis. These respirations do not exhibit alternating periods of hyperventilation and apnea, so this option is not applicable.
C) Apneustic respirations: Apneustic respirations are characterized by prolonged inhalation followed by a prolonged pause before exhalation. This pattern does not align with the alternating hyperventilation and apnea described, making it an incorrect choice.
D) Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by a cyclical pattern of increasing depth and rate of breathing followed by a gradual decrease in depth and a period of apnea. This description matches the client's breathing pattern of alternating hyperventilation and apnea, making this the correct answer.
Correct Answer is D
Explanation
Keeping the drainage system below the level of the client's chest prevents backflow of fluid or air into the pleural space and maintains negative pressure in the system.
a) Disconnecting the chest tube from the drainage system during transport is dangerous and can cause pneumothorax, infection, or bleeding. The chest tube should remain connected to the drainage system at all times unless ordered by the provider.
b) Emptying the collection chamber prior to transport is unnecessary and can interfere with accurate measurement of drainage. The collection chamber should be emptied only when it is full or at the end of each shift.
c) Clamping the chest tube prior to transferring the client to a wheelchair is contraindicated and can cause tension pneumothorax, as it prevents air from escaping the pleural space. The chest tube should only be clamped for a brief period when changing the drainage system or checking for air leaks, and only with a provider's order.
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