A client's respiratory assessment reveals crackles, decreased tactile fremitus, and a dull sound in left lower chest during percussion. Which condition should the nurse document in the electronic medical record?
Pleural effusion.
Emphysema.
Bronchitis.
Pneumothorax.
The Correct Answer is A
A. Pleural effusion: The combination of crackles, decreased tactile fremitus, and dullness to percussion is most consistent with pleural effusion. Fluid in the pleural space dampens vibration transmission, decreases fremitus, and creates a dull percussion sound while causing adventitious breath sounds.
B. Emphysema: Emphysema typically presents with hyperresonance on percussion due to air trapping, along with diminished breath sounds. Fremitus is decreased as well, but crackles and dullness are not characteristic findings.
C. Bronchitis: Bronchitis may cause crackles or wheezes due to airway inflammation, but tactile fremitus is usually normal or increased, and percussion tones remain resonant. The dullness noted here makes bronchitis unlikely.
D. Pneumothorax: Pneumothorax produces hyperresonant percussion sounds with absent or markedly decreased breath sounds. Fremitus is also decreased, but dullness and crackles are not expected, distinguishing it from pleural effusion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Glucose and calcium levels: While hyperglycemia can occur secondary to stress, glucose and calcium are not the primary indicators of severity in a thyrotoxic crisis.
B. Blood and urine cultures: Cultures are important if infection is suspected as a trigger, but they do not reflect the systemic impact of a thyrotoxic crisis itself.
C. Renal and liver function tests: Thyrotoxic crisis can lead to multi-organ stress, including hepatic dysfunction and impaired renal perfusion. Monitoring liver enzymes and renal function helps detect complications early and guide interventions.
D. Electrolytes and hemoglobin: Electrolytes may fluctuate and anemia may exist, but they are not the most critical values to monitor during the acute phase of a thyrotoxic crisis compared with organ function indicators.
Correct Answer is D
Explanation
A. Morphine can be administered for chest pain to reduce discomfort and anxiety, and it does not have a direct dangerous interaction with sildenafil.
B. Aspirin is commonly used in chest pain management to prevent platelet aggregation and does not interact dangerously with sildenafil.
C. Heparin is an anticoagulant used in acute coronary syndrome; it is safe to administer with sildenafil and does not pose an immediate interaction risk.
D. Nitroglycerin and other nitrates can cause severe hypotension when combined with sildenafil. Withholding nitrates is essential to prevent life-threatening drops in blood pressure in this client.
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