A nurse is collecting data for 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

Answer and Explanation

The Correct Answer is C

A. Respiratory alkalosis: Respiratory alkalosis is generally associated with hyperventilation and is not directly caused by tension pneumothorax. In tension pneumothorax, the primary issues are related to pressure changes within the thoracic cavity, not respiratory alkalosis.

B. Increased venous return: In tension pneumothorax, venous return is actually decreased due to the increased intrathoracic pressure compressing the great vessels, which impedes blood flow back to the heart.

C. Decreased cardiac output: Tension pneumothorax causes a significant increase in intrathoracic pressure, leading to compression of the heart and great vessels, which results in decreased venous return and ultimately decreased cardiac output. This is a critical and life-threatening consequence of tension pneumothorax.

D. Dilated ventricles: Dilated ventricles are more commonly seen in chronic heart conditions such as heart failure, rather than in acute tension pneumothorax. Tension pneumothorax typically results in reduced ventricular filling rather than dilation.

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Correct Answer is B

Explanation

A. Respiratory acidosis occurs due to hypoventilation, resulting in carbon dioxide retention. This condition is characterized by slow, shallow breathing and confusion, which is not consistent with the client's rapid respiratory rate of 30/min.
B. Respiratory alkalosis is typically caused by hyperventilation, where excessive breathing leads to a decrease in carbon dioxide levels. The client's symptoms of high anxiety and rapid, shallow respirations are indicative of hyperventilation, making respiratory alkalosis the most likely diagnosis.
C. Metabolic acidosis is characterized by deep, rapid breathing (Kussmaul respirations) as the body attempts to expel excess acid. The client's shallow respirations are inconsistent with the breathing pattern seen in metabolic acidosis.
D. Metabolic alkalosis usually presents with symptoms such as dizziness and tingling, often with compensatory slow respirations. The rapid respiratory rate in this case does not suggest metabolic alkalosis, making this option unlikely.

A. (Select All that Apply.) B. The client who has renal failure C. The client who is postoperative following a thyroidectomy D. The client who has hyperparathyroidism E. The client who has vitamin D deficiency F. The client who is receiving bisphosphonate medications

Correct Answer is ["A","B","D","E"]

Explanation

A. The client who has renal failure: Renal failure can lead to hypocalcemia due to the kidneys' reduced ability to convert vitamin D to its active form, leading to decreased calcium absorption.

B. The client who is postoperative following a thyroidectomy: Hypocalcemia can occur after thyroidectomy if the parathyroid glands are inadvertently damaged or removed, as they regulate calcium levels.

C. The client who has hyperparathyroidism: Hyperparathyroidism typically leads to hypercalcemia, not hypocalcemia, as excessive parathyroid hormone (PTH) increases calcium levels in the blood.

D. The client who has vitamin D deficiency: Vitamin D is essential for calcium absorption in the intestines, so a deficiency can lead to hypocalcemia.

E. The client who is receiving bisphosphonate medications: Bisphosphonates inhibit bone resorption, which can lead to a decrease in calcium levels, potentially causing hypocalcemia.

F. The client who has Addison's disease: Addison's disease is primarily associated with electrolyte imbalances like hyponatremia and hyperkalemia, not hypocalcemia.

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A nurse is collecting data for a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?

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