NSG 233 MED SURGE FINAL EXAM 1 LATEST VERSION 2024 WITH 200 QUESTIONS AND ANSWERS GRADED A+/ NSG 233 MED SURGE ACTUAL FINAL EXAM QUESTIONS AND CORRECT ANSWERS LATEST 2024 (BRAND NEW!!)
Scenario: The nurse notes that Mr. U has tracheal deviation. Tension
pneumothorax is suspected because of the sudden onset respiratory distress and the
presence of the chest tube, which is a risk factor.
Which signs and symptoms would the nurse expect to observe with a tension
pneumothorax? Select all that apply.
1. Tachypnea
2. Paradoxical chest movement
3. Hemoptysis
4. Profuse diaphoresis
5. Distended jugular veins
6. Decreased or absent breath sounds on the affected side
7. Bradycardia
8. Lateral or medial shift in the point of maximum impulse
9. Severe dyspnea
10. Progressive cyanosis
11. Extreme agitation - ANSWER-1, 4, 5, 6, 8, 9, 10, 11
Rational:
Tension pneumothorax is a medical emergency that occurs when air enters the
pleural space but cannot escape. Pressure builds up on the affected lung, heart, and
the great vessels. A mediastinal shift occurs when continued pressure pushes
against the unaffected lung and oxygenation and perfusion are further
compromised. For Mr. U, the tension pneumothorax is most likely to be associated with the chest tube. Tachycardia, not bradycardia, is expected.
Hemoptysis is more likely to occur with a hemopneumothorax. Paradoxical chest
movements are associated with flail chest secondary to rib fractures.
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