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:

Auscultation at the pulmonic and mitral points would not provide the clearest hearing of the S2 heart sound. The S2 sound is composed of two components: A2 (aortic valve closure) and P2 (pulmonic valve closure). The aortic valve sound (A2) is usually louder than P2. Mitral point is not ideal for hearing S2 clearly, as it's mostly associated with S1 sound.

Choice B rationale:

The tricuspid and aortic points are the most appropriate for hearing the S2 heart sound. The aortic valve (A2) is best heard at the second right intercostal space close to the sternum, and the tricuspid valve is best heard at the lower left sternal border.

Choice C rationale:

While the mitral and tricuspid points are important for auscultating the heart sounds, they are more associated with the S1 sound (the first heart sound). The S2 sound is best heard at the aortic and pulmonic areas.

Choice D rationale:

The aortic and pulmonic points are important for assessing the S2 heart sound, but they are not the most optimal locations. The aortic valve sound is heard most clearly at the second right intercostal space, whereas the pulmonic valve sound is heard at the second left intercostal space.

A. "Cranberry juice can cause bad breath.". B. "You may experience bloating.". C. "Drinking cranberry juice daily can prevent recurrent urinary tract infections.". D. "Cranberry juice can lower cholesterol.".

Correct Answer is C

Explanation

Choice A rationale:

Cranberry juice causing bad breath is not a well-known side effect or outcome associated with its consumption. This information is not a commonly taught aspect of cranberry juice use.

Choice B rationale:

Bloating is not a common or widely recognized outcome of drinking cranberry juice. While cranberry juice might have some gastrointestinal effects, bloating is not a significant concern associated with its consumption.

Choice C rationale:

Informing the client that drinking cranberry juice daily can prevent recurrent urinary tract infections is accurate. Cranberry juice is often recommended for its potential to reduce the risk of urinary tract infections due to its anti-adhesive properties that may inhibit the adherence of bacteria to the urinary tract.

Choice D rationale:

Cranberry juice's effect on lowering cholesterol is not a well-established benefit of its consumption. Cholesterol management typically involves dietary changes, exercise, and sometimes medications, but cranberry juice is not a primary intervention for this purpose.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A Medical-Surgical nurse is assessing a client's heart sounds. In which of the following points of auscultation would the nurse hear the S2 sound most clearly?

Correct Answer is B

Explanation

A Medical-Surgical nurse is teaching a client about the uses of cranberry juice. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is teaching a client's spouse about how to obtain a blood pressure reading. Which of the following actions by the spouse indicates a need for further instruction?

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to see in this client? (Select all that apply.).

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 on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?

A nurse on a Medical-Surgical unit is preparing to administer an intramuscular injection to a client. Which of the following sites can the nurse use? (Select all that apply.).

A nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching?