A trauma client has experienced a ruptured diaphragm. The nurse would anticipate that this client will have difficulty:
1. with an elevated oxygen level.
2. primarily during exhalation.
3. maintaining a high enough respiratory rate.
4. carrying out the respiratory cycle.
Correct Answer: 4
Rationale 1: The oxygen level would be low because of inadequate ventilation.
Rationale 2: Both inhalation and exhalation would be impaired.
Rationale 3: The client's chest will be unable to move adequately, and the respiratory rate will increase in an effort to increase oxygenation.
Rationale 4: Contraction and relaxation of the diaphragm are essential to the ventilation segment of the respiratory cycle.
Global Rationale: Ventilation is the process of moving air into and out of the lungs. As the diaphragm contracts and lowers in position, it creates a negative pressure that draws air into the lungs and inspiration occurs. During expiration the diaphragm relaxes and air leaves the lungs passively. The oxygen level would be low because of inadequate ventilation. Both inhalation and exhalation would be impaired. The client's chest will be unable to move adequately, and the respiratory rate will increase in an effort to increase oxygenation.
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