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 C

Explanation

The correct answer is Choice C, the system is working properly.

Choice A rationale: The lung has re-expanded is incorrect. If the lung has re-expanded, there would be no tidaling in the water seal chamber, as the pleural space would be restored to its normal negative pressure.Tidaling indicates that there is still air or fluid in the pleural space that needs to be drained

Choice B rationale: There is a loop of tubing below the drainage system is incorrect. A loop of tubing below the drainage system would not cause tidaling in the water seal chamber, but it could cause fluid accumulation in the tubing, which could impair the drainage and increase the risk of infection.The tubing should be straight and free of kinks or loops

Choice C rationale: The system is working properly is correct. Tidaling in the water seal chamber means that the water level rises and falls with the patient’s respirations. This is normal and expected, as it indicates that the chest tube is patent and connected to the pleural space, and that the drainage system is airtight and preventing air or fluid from entering the pleural space.Tidaling should stop when the lung is fully re-expanded or the chest tube is clamped

Choice D rationale: The tubing is partially obstructed by clots is incorrect. If the tubing is partially obstructed by clots, there would be no tidaling in the water seal chamber, as the chest tube would not be able to drain the air or fluid from the pleural space. The water level in the water seal chamber would be stagnant, and the patient may experience respiratory distress.The tubing should be checked regularly for clots and milked gently if needed

A. Spotting. B. Nausea. C. Board-like abdomen. D. Delayed menses.

Correct Answer is A

Explanation

Choice A rationale:

Spotting is a common finding in placenta previa. It occurs due to the abnormal implantation of the placenta over or near the cervical os, leading to vaginal bleeding. This bleeding can range from mild spotting to severe hemorrhage and is a significant sign of placenta previa.

Choice B rationale:

Nausea is not a specific sign of placenta previa. Nausea and vomiting are common symptoms during early pregnancy but are not directly related to placenta previa.

Choice C rationale:

A board-like abdomen is a sign of peritonitis or an acute abdomen, which is not associated with placenta previa. This finding suggests intra-abdominal inflammation and is unrelated to the condition in question.

Choice D rationale:

Delayed menses is a common sign of pregnancy, but it does not specifically indicate placenta previa. Placenta previa is characterized by vaginal bleeding, which is not synonymous with a delay in menstrual periods.

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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?

Nursing Test Bank

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A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling?

Correct Answer is C

Explanation

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Correct Answer is A

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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?