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 D
Explanation
A. Administer prescribed PRN sleep medications: While adequate rest is important for postpartum recovery, it does not address the immediate risk to the client’s healing perineal tissue and comfort related to the fourth-degree laceration.
B. Encourage use of prescribed analgesic perineal sprays: Pain management is important for comfort and mobility, but it does not prevent complications such as wound disruption or trauma during defecation, which could impair healing.
C. Encourage breastfeeding to promote uterine involution: Breastfeeding supports uterine contraction and reduces postpartum bleeding, but it does not directly impact the care and protection of a severe perineal laceration.
D. Administer prescribed stool softener: Preventing straining during bowel movements is critical in promoting healing of a fourth-degree perineal laceration. Stool softeners reduce the risk of trauma to the repaired tissue, prevent pain, and minimize potential complications such as wound dehiscence.
Correct Answer is C
Explanation
A. Prone: Prone positioning limits assessment of spinal curvature, extremity alignment, and body symmetry because the client is lying on the abdomen, which can obscure certain postural deviations.
B. Sims: Sims position is primarily used for rectal or vaginal procedures and does not provide a full view of overall body alignment, making it less ideal for assessment purposes.
C. Supine: Supine position allows the client to lie flat on the back with the body fully supported. This position provides the best view of the head, neck, spine, shoulders, hips, and extremities for a comprehensive assessment of body alignment.
D. Fowlers: Fowlers position elevates the head and torso, which may alter natural spinal alignment and obscure an accurate assessment of posture and symmetry compared with a flat, supine position.
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