A client presents to the emergency room reporting sudden, sharp pain on the right side of the chest and shortness of breath. The right side of the chest is not moving with inspiration. The client's trachea is deviated towards the left: there is absence tactile fremitus on the right side of the chest. Upon percussion, the nurse hears hyperresonant sound on the right side of the thorax. Upon auscultation, no breath sounds are heard on the right. Which disorder would the nurse suspect?

Asthma.

Pneumothorax.

Atelectasis.

Pneumonia.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Asthma - Asthma is a chronic respiratory condition characterized by bronchoconstriction, inflammation, and increased mucus production. It does not typically present with absent breath sounds, deviation of the trachea, or hyperresonant percussion sounds. Wheezing is a common finding in asthma.

Choice B rationale:

Pneumothorax - This is the correct choice. The scenario describes classic signs of a tension pneumothorax, which is a medical emergency. The tracheal deviation, absence of breath sounds, and hyperresonant percussion note on the affected side are indicative of air accumulation in the pleural space, leading to lung collapse and displacement of mediastinal structures.

Choice C rationale:

Atelectasis - Atelectasis refers to the collapse or incomplete expansion of a lung or part of a lung. It can lead to decreased breath sounds on auscultation but does not usually cause tracheal deviation or hyperresonance on percussion. It is not the best fit for the described signs.

Choice D rationale:

Pneumonia - Pneumonia is an infection of the lung tissue that can cause symptoms like fever, cough, and productive sputum. Breath sounds may be diminished over the affected area due to consolidation, but the absence of breath sounds, tracheal deviation, and hyperresonance point more strongly toward a pneumothorax in this case.

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Correct Answer is B

Explanation

Choice A rationale:

Restricting the client's fluid intake to less than 2 L/day is not an appropriate intervention for a client with COPD. Adequate hydration is important to help thin mucus secretions and improve respiratory function. Restricting fluids can lead to thicker mucus and exacerbate breathing difficulties.

Choice B rationale:

Instructing the client to use pursed-lip breathing is a beneficial intervention for someone with COPD. Pursed-lip breathing helps improve breathing efficiency by promoting better air exchange and preventing air trapping, which is common in COPD. It helps slow down breathing and increases oxygen saturation.

Choice C rationale:

Having the client use the early-morning hours for exercise and activity might not be the best choice. Morning hours can be when clients with COPD experience more respiratory symptoms. It's advisable to schedule activities during times when the client feels more comfortable and less breathless.

Choice D rationale:

Providing the client with a low-protein diet is not a relevant intervention for COPD management. COPD primarily affects the lungs and respiratory system, and a low-protein diet is not a standard part of its management. Nutritional recommendations for COPD typically focus on maintaining a balanced diet to support overall health.

A. Partial-thickness skin loss. B. Necrotic subcutaneous tissue. C. Blood-filled blisters. D. Exposed bone.

Correct Answer is B

Explanation

The correct answer is choice B. Necrotic subcutaneous tissue.

Choice A rationale:

Partial-thickness skin loss (Choice A) is characteristic of a stage II pressure ulcer, not a stage III ulcer. A stage II pressure ulcer involves the loss of the epidermis and possibly the dermis, resulting in a shallow open ulcer with a red-pink wound bed.

Choice B rationale:

Necrotic subcutaneous tissue is a manifestation of a stage III pressure ulcer. A stage III ulcer involves full-thickness skin loss where subcutaneous fat may be visible, but exposed bone or muscle is not yet present. Necrotic tissue in the wound bed indicates a more advanced level of tissue damage and the need for appropriate wound care to promote healing.

Choice C rationale:

Blood-filled blisters (Choice C) are not specific to pressure ulcers and are more commonly associated with friction or shear forces. These blisters are not indicative of a stage III pressure ulcer, which involves visible full-thickness tissue loss.

Choice D rationale:

Exposed bone (Choice D) is a characteristic of a stage IV pressure ulcer, not a stage III ulcer. A stage IV ulcer involves extensive tissue loss with exposure of muscle, tendon, or bone. This represents a severe level of tissue damage and requires intensive wound care and management.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

Correct Answer is B

Explanation

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Correct Answer is B

Explanation

While preparing to administer the patient's scheduled medications, the nurse does not understand why the client will be receiving one of the prescribed drugs. What action should the nurse take?

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

A nurse sees an assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first?

A Medical-Surgical nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.).

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?