A nurse is assessing a client who has a possible right pneumothorax.
Which of the following findings should the nurse expect?
Paradoxical chest movement.
Reduced right-sided breath sounds.
High-pitched stridor.
Intercostal retractions.
The Correct Answer is B
Choice A rationale:
Paradoxical chest movement refers to the abnormal inward movement of the chest during inhalation and outward movement during exhalation. It is not a typical finding in pneumothorax. Instead, paradoxical chest movement is often observed in conditions such as flail chest.
Choice B rationale:
Reduced right-sided breath sounds are a common finding in right pneumothorax. Air in the pleural space can cause lung collapse, leading to decreased or absent breath sounds on the affected side.
Choice C rationale:
High-pitched stridor is a sound heard during inspiration and indicates upper airway obstruction, often due to conditions like croup or epiglottitis. It is not a characteristic finding in pneumothorax.
Choice D rationale:
Intercostal retractions occur when the tissues between the ribs are pulled inward during inspiration. While retractions can be seen in various respiratory distress conditions, they are not specific to pneumothorax.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choiceb. Obtain a CBC with differential.
Choice A rationale:
Drawing blood specimens for culture and sensitivity is not typically required before a cardiac catheterization unless there is a specific concern about infection.
Choice B rationale:
Obtaining a CBC with differential is important to assess the client’s overall health and detect any potential issues such as anemia or infection that could complicate the procedure.
Choice C rationale:
Transporting the client to radiology for a CT scan is not a standard pre-procedure task for cardiac catheterization. This might be necessary if there are specific indications, but it is not routine.
Choice D rationale:
Administering nitroglycerin 0.4 mg SL 30 minutes before the procedure is not a standard practice for preparing a client for cardiac catheterization.Nitroglycerin is typically used to manage chest pain or angina, not as a pre-procedure medication.
Correct Answer is A
Explanation
Choice A rationale:
Providing a verbal report of the client's condition to the paramedic performing the transfer violates the client's confidentiality. Protected health information should not be disclosed verbally to individuals who do not have a need to know. Confidentiality must be maintained during all stages of care, including transfers.
Choice B rationale:
Faxing the client's name and identifiable information to the rehabilitation facility is not a secure method of transmitting sensitive health information. Faxed documents can be intercepted, compromising the client's confidentiality. Secure electronic methods or encrypted communication should be used for transmitting such information.
Choice C rationale:
Emailing the client's health information to the facility in an unencrypted file is also insecure and violates the client's confidentiality. Unencrypted emails can be intercepted and read by unauthorized individuals. Protected health information should be transmitted using secure, encrypted methods to maintain confidentiality.
Choice D rationale:
Discussing the client's response to the transfer with another staff nurse is inappropriate and breaches confidentiality. Sharing patient information, even within the healthcare team, should only be done on a need-to-know basis and in a secure, private setting.
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