A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax?

Diminished breath sounds

Distended neck veins

Irregular heart rate

Itching over the incision

Answer and Explanation

The Correct Answer is A

A. Diminished breath sounds: A pneumothorax occurs when air accumulates in the pleural space, leading to lung collapse. This results in reduced air entry, causing diminished or absent breath sounds on the affected side. Other symptoms may include dyspnea, tachypnea, and chest pain.

B. Distended neck veins: Neck vein distention is more commonly associated with conditions such as cardiac tamponade or superior vena cava syndrome. A pneumothorax typically causes respiratory distress rather than venous congestion. If a tension pneumothorax develops, neck vein distention may occur, but it is not an early or primary sign.

C. Irregular heart rate: While severe cases of pneumothorax can cause cardiovascular compromise due to pressure on the heart and great vessels, an irregular heart rate is not a direct or early indicator. Cardiac arrhythmias are more often seen with electrolyte imbalances, cardiac ischemia, or other primary heart conditions.

D. Itching over the incision: Itching at the catheter insertion site is a common postoperative reaction, often related to healing, adhesive irritation, or mild inflammation. It is not indicative of a pneumothorax, which primarily presents with respiratory distress and absent or diminished breath sounds.

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Correct Answer is D

Explanation

A. Asystole: Synchronized cardioversion is ineffective for asystole because there is no electrical activity to reset. The appropriate intervention for asystole is immediate CPR and administration of epinephrine.

B. Ventricular fibrillation: Defibrillation, not synchronized cardioversion, is the appropriate treatment for ventricular fibrillation because it is a pulseless, chaotic rhythm that requires immediate high-energy shocks.

C. Pulseless ventricular tachycardia: Pulseless ventricular tachycardia is treated with defibrillation rather than synchronized cardioversion, as there is no coordinated cardiac activity to synchronize with. CPR and advanced cardiac life support (ACLS) protocols should be initiated.

D. Atrial fibrillation: Synchronized cardioversion is indicated for atrial fibrillation, particularly when it is associated with hemodynamic instability. Cardioversion helps restore a normal sinus rhythm by delivering a shock synchronized to the R wave of the QRS complex.

A. A client who has aspiration pneumonia B. A client who is receiving continuous gastric suctioning C. A client who is experiencing an opioid overdose D. A client who has uncontrolled diabetes mellitus

Correct Answer is B

Explanation

A. A client who has aspiration pneumonia: Pneumonia leads to hypoventilation and carbon dioxide retention, which causes respiratory acidosis. It does not typically result in metabolic alkalosis since it affects gas exchange rather than acid-base balance at the metabolic level.

B. A client who is receiving continuous gastric suctioning: Prolonged removal of gastric secretions depletes hydrochloric acid, leading to an excess of bicarbonate in the blood and resulting in metabolic alkalosis. This is a common cause of alkalosis, along with excessive vomiting or diuretic use.

C. A client who is experiencing an opioid overdose: Opioids depress the respiratory system, reducing ventilation and causing carbon dioxide buildup, leading to respiratory acidosis. This does not cause metabolic alkalosis, as the issue originates in the lungs, not metabolism.

D. A client who has uncontrolled diabetes mellitus: Diabetic ketoacidosis results in excessive production of acidic ketone bodies, which lower blood pH and cause metabolic acidosis. The acid-base disturbance in diabetes is typically acidosis, not alkalosis.

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A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax?

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