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 B

Explanation

In the context of an emergency response plan following an external disaster and the need to create bed space for potential admissions, the nurse should consider early discharge for clients who are stable and whose discharge will not compromise their safety or health. Based on the given options, the most appropriate candidate for early discharge would be:

B) A client who is 1 day postoperative following a vertebroplasty.

Clients who are one day postoperative after a vertebroplasty are typically recovering from a relatively minor procedure and may be stable for discharge if their condition remains uncomplicated.

The other options:

A) A client receiving heparin for deep-vein thrombosis may require ongoing monitoring and treatment, and early discharge might not be appropriate.

C) A client with cancer and a sealed implant for radiation therapy likely has specific treatment needs and should not be discharged early.

D) A client with COPD and a respiratory rate of 44/min likely has respiratory distress and should not be discharged early. Their condition requires close monitoring and intervention.

A. Administering potassium via IV bolus. B. Leaving a nasogastric tube clamped after administering oral medication. C. Placing a yellow bracelet on a client who is at risk for falls. D. Documenting communication with a provider in the progress notes of the client's medical record.

Correct Answer is A

Explanation

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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?