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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Answer is: a. "The estimated blood loss was 250 milliliters."

Explanation: Including the estimated blood loss during the procedure in the hand-off report is relevant information that impacts the patient's care and helps the receiving nurse assess the patient's condition and monitor for complications.

Choice b. is wrong because the client has been transferred to the PACU, it is implied that the intubation has been removed. The focus should be on the patient's current condition and any potential complications related to the procedure.

Choice c. is wrong because the client's role as a member of the board of directors does not directly affect their medical care. Nurses should maintain patient confidentiality and only discuss relevant information regarding the patient's health status.

Choice d. is wrong because the number of sponges used during the procedure is not essential information to include in the hand-off report. The focus should be on the patient's current condition and any potential complications.

A. Draw blood specimens for culture and sensitivity. B. Obtain a CBC with differential. C. Transport the client to radiology for a CT scan. D. Administer nitroglycerin 0.4 mg SL 30 min before the procedure.

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.

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A nurse is assessing a client who has a possible right pneumothorax.Which of the following findings should the nurse expect?

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A nurse is assessing a client who has a possible right pneumothorax.
Which of the following findings should the nurse expect?