A nurse is assessing a client following the insertion of a central venous catheter.

Which of the following findings indicates a pneumothorax?

Distended neck veins.

Itching over the incision.

Irregular heart rate.

Diminished breath sounds.

Answer and Explanation

The Correct Answer is D

A pneumothorax is a collapsed lung that occurs when air leaks into the space between the lung and the chest wall.
This can cause diminished breath sounds on the affected side. Distended neck veins are not a symptom of pneumothorax.
B) Itching over the incision is not a symptom of pneumothorax.
C) Irregular heart rate is not a symptom of pneumothorax.

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Correct Answer is C

Explanation

Platelets 70,000/mm.
The priority finding for a nurse assessing a client who has cirrhosis to report is a platelet count of 70,000/mm.
A low platelet count (thrombocytopenia) can be a complication of cirrhosis and can increase the risk of bleeding.
A platelet count below 150,000/mm3 is considered low and should be reported to the provider.
Choice A is incorrect because while a distended abdomen can be a sign of ascites, a complication of cirrhosis, it is not the priority finding to report.
Choice B is incorrect because while clay-colored stools can be a sign of biliary obstruction, it is not the priority finding to report.
Choice D is incorrect because while an elevated alkaline phosphatase level can be a sign of liver damage, it is not the priority finding to report.

A. Urinary diuresis. B. Hypotension. C. Decreased respiratory rate. D. Bradycardia.

Correct Answer is B

Explanation

A full-thickness burn injury can result in fluid loss and low blood volume (hypovolemia), which can lead to hypotension.

Choice A, Urinary diuresis, is not the correct answer because it refers to increased production of urine and is not a common symptom of a full-thickness burn injury.
Choice C, Decreased respiratory rate, is not the correct answer because it refers to a decrease in the number of breaths per minute and is not a common symptom of a full-thickness burn injury.

Choice D, Bradycardia, is not the correct answer because it refers to a slow heart rate and is not a common symptom of a full-thickness burn injury.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report?

Correct Answer is C

Explanation

A nurse is caring for a client in the emergency department who experienced a full-thickness burn injury to the lower torso 1 hr ago. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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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?