NCLEX-RN · Question #48
In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by:
The correct answer is C. Palpating for trachial deviation. (A) No change in the breath sounds occurs as a direct result of the mediastinal shift. (B) Crepitus can occur owing to the primary disorder, not to the mediastinal shift. (C) Mediastinal shift occurs primarily with tension pneumothorax, but it can occur with very large…
Question
In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by:
Options
- AAuscultating bilateral breath sounds
- BPalpating for presence of crepitus
- CPalpating for trachial deviation
- DAuscultating heart sounds
How the community answered
(31 responses)- B3% (1)
- C94% (29)
- D3% (1)
Explanation
(A) No change in the breath sounds occurs as a direct result of the mediastinal shift. (B) Crepitus can occur owing to the primary disorder, not to the mediastinal shift. (C) Mediastinal shift occurs primarily with tension pneumothorax, but it can occur with very large hemothorax or pneumothorax. Mediastinal shift causes trachial deviation and deviation of the heart'spoint of maximum impulse. (D) No change in the heart sounds occurs as a result of the mediastinal shift.
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