A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?
Respiratory alkalosis
Increased venous return
Decreased cardiac output
Dilated ventricles
The Correct Answer is C
Choice A Reason:
Respiratory alkalosis is incorrect. Tension pneumothorax typically leads to respiratory distress and hypoxemia rather than respiratory alkalosis. The respiratory alkalosis may occur initially due to hyperventilation in response to hypoxemia but would not be directly related to tracheal deviation.
Choice B Reason:
Increased venous return is incorrect. Tension pneumothorax actually leads to decreased venous return due to compression of the great vessels in the thorax, particularly the superior vena cava and the inferior vena cava. This compression results from the increased pressure within the thorax, which impedes blood flow back to the heart.
Choice C Reason:
Decreased cardiac output is incorrect. Tension pneumothorax can indeed lead to decreased cardiac output due to compression of the heart and the great vessels by the accumulating air in the pleural space. This compression decreases venous return and impairs cardiac function.
Choice D Reason:
Dilated ventricles is incorrect. As mentioned earlier, tension pneumothorax can lead to compression of the heart, including the ventricles. This compression can cause dilatation of the ventricles, particularly the right ventricle, due to increased afterload and decreased venous return.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Higher oxygen saturations of 98% to 99% is inappropriate. A pneumothorax involves the presence of air in the pleural space, which can compromise lung function and gas exchange. This compromised lung function typically leads to decreased oxygenation of the blood, resulting in lower oxygen saturations rather than higher saturations.
Choice B Reason:
Lower oxygen saturations of 93% to 94% is appropriate. A pneumothorax disrupts the normal exchange of oxygen and carbon dioxide in the lungs due to partial or complete lung collapse. As a result, the affected lung is unable to adequately oxygenate the blood, leading to lower oxygen saturations, which are indicative of hypoxemia.
Choice C Reason:
Lower energy expenditure is inappropriate. Energy expenditure is not typically affected by a pneumothorax. While the discomfort and respiratory distress associated with a pneumothorax may cause the individual to limit physical activity, there is no direct impact on overall energy expenditure.
Choice D Reason:
Increased lung capacity is inappropriate. A pneumothorax results in partial or complete collapse of the affected lung, reducing lung capacity rather than increasing it. The presence of air in the pleural space creates positive pressure, which can compress the lung and decrease its ability to expand fully during inhalation.
Correct Answer is C
No explanation
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