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 C
Explanation
Step 1: Convert the dopamine hydrochloride dose from mcg to mg. We know that 1 mg = 1000 mcg. So, 4 mcg = 0.004 mg.
Step 2: Calculate the total amount of dopamine hydrochloride the client needs per minute. We know that the client weighs 80 kg and the dose is 0.004 mg/kg/min. So, 0.004 mg/kg/min × 80 kg = 0.32 mg/min.
Step 3: Convert the total amount of dopamine hydrochloride the client needs per minute to an hourly rate. We know that 1 hour = 60 minutes. So, 0.32 mg/min × 60 min/hr = 19.2 mg/hr.
Step 4: Calculate the volume of the solution that contains 19.2 mg of dopamine hydrochloride. We know that the solution contains 800 mg in 250 mL. So, (19.2 mg ÷ 800 mg) × 250 mL = 6 mL.
Therefore, the nurse should set the IV infusion to deliver 6 mL/hr (rounded to the nearest whole number).
Correct Answer is B
Explanation
The correct answer is Choice B: Assign the child to a negative air pressure room.
Choice A rationale: Assessing the child for Koplik spots is not appropriate in this situation because Koplik spots are associated with measles, not varicella. Koplik spots are small, white, irregular lesions that appear on the buccal mucosa during the prodromal phase of measles. They do not present in cases of varicella, which is characterized by a pruritic, vesicular rash.
Choice B rationale: Assigning the child to a negative air pressure room is the most suitable action because varicella is highly contagious and can be transmitted through airborne particles. A negative air pressure room helps to contain these particles and minimize the risk of infection transmission to other patients, healthcare workers, and visitors. Airborne precautions are the recommended infection control measures for managing varicella cases in healthcare settings.
Choice C rationale: Utilizing droplet precautions alone is insufficient for managing varicella because the virus can also be spread through airborne particles. While droplet precautions may be a component of the overall infection control strategy, they are inadequate without the additional implementation of airborne precautions, such as a negative air pressure room.
Choice D rationale: Administering aspirin to a child with a viral illness is generally contraindicated due to the potential risk of Reye's syndrome, a rare but severe condition characterized by liver failure and encephalopathy. It is essential to follow appropriate guidelines for managing fever and discomfort in pediatric patients with varicella, which typically involve using acetaminophen or ibuprofen instead of aspirin.
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