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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The choice "Patient ate half of his breakfast tray" is not the correct answer. While poor appetite or decreased intake can impact a patient's nutritional status, it is not a direct indicator of pressure ulcer risk.
Choice B rationale:
The choice "Patient has a raised erythematous rash below the knee" is not the correct answer. This might indicate a localized skin issue, such as an allergic reaction or dermatitis, but it is not a clear sign of pressure ulcer risk.
Choice C rationale:
The choice "Patient has a capillary refill of less than 2 seconds" is not the correct answer. Capillary refill time assesses peripheral circulation and is useful in evaluating perfusion, but it is not specifically indicative of pressure ulcer risk.
Choice D rationale:
The correct answer is "Patient is incontinent of stool." Choice D is the correct answer. Incontinence, especially fecal incontinence, increases the risk of pressure ulcer development. Prolonged exposure to moisture from urine or stool weakens the skin's integrity, making it more susceptible to breakdown when pressure is applied over bony prominences.
Correct Answer is C
Explanation
Choice A rationale:
Admission assessment of a new client requires comprehensive evaluation, critical thinking, and clinical judgment. This task is within the scope of a registered nurse's responsibilities and should not be delegated to an LPN.
Choice B rationale:
Evaluating changes to a client's pressure ulcer also involves clinical judgment and assessment skills that fall within the domain of a registered nurse's role.
Choice C rationale:
This is the correct choice. Tracheostomy care involves routine and standardized procedures that an LPN can perform under the supervision of a registered nurse. LPNs are trained to provide this type of care safely and effectively.
Choice D rationale:
Administering a blood transfusion is a complex procedure that requires careful monitoring and assessment for potential adverse reactions. This task is typically within the scope of a registered nurse's practice, not an LPN's.
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