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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The "Choice of Analgesia and Sedation" component of the ABCDEF assessment tool focuses on selecting appropriate pain relief and sedation strategies for the patient but does not directly relate to the weaning process.
B. "Assess, Prevent, and Manage Pain" involves ensuring the patient is comfortable and free from pain, which is important but not specifically related to weaning from the ventilator.
C. "Delirium: Assess, Prevent, and Manage" addresses the cognitive status of the patient, particularly the prevention and management of delirium, which is a critical aspect of care but not directly related to ventilator weaning.
D. "Breathing: Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)" directly involves the weaning process, as it includes assessing the patient's ability to breathe independently by reducing or removing sedation (SAT) and evaluating their capacity for spontaneous breathing (SBT).
Correct Answer is B
Explanation
A. Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation before suctioning is a method to prevent hypoxia, not to thin secretions. It does not affect the viscosity of secretions.
B. Provide humidified oxygen: Humidified oxygen helps to moisten the airways, which can thin secretions, making them easier to clear. This is an appropriate intervention for managing tenacious secretions in a client with a tracheostomy.
C. Perform chest physiotherapy prior to suctioning: Chest physiotherapy helps mobilize secretions but does not thin them. While useful in clearing airways, it is not a direct method for thinning secretions.
D. Prelubricate the suction catheter tip with sterile saline when suctioning the airway: Prelubricating the suction catheter is done to reduce friction and trauma during suctioning but does not impact the thickness of the secretions.
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