A nurse is caring for a client who has a tension pneumothorax. Which of the following manifestations should the nurse expect?
Paradoxical chest movement
Bilateral crackles
Asymmetry of the chest
Blood-tinged sputum
The Correct Answer is C
Rationale:
A. Paradoxical chest movement: Paradoxical chest movement is typically associated with flail chest, where multiple rib fractures cause a segment of the chest wall to move in the opposite direction during breathing. It is not a characteristic finding of tension pneumothorax, which involves intrathoracic pressure buildup rather than rib instability.
B. Bilateral crackles: Bilateral crackles are usually indicative of fluid in the alveoli, such as in pulmonary edema or pneumonia. Tension pneumothorax generally causes decreased or absent breath sounds on the affected side, not crackles, due to lung collapse.
C. Asymmetry of the chest: Tension pneumothorax often causes visible asymmetry of the chest because the affected side may appear distended while the other side may appear sunken. The increased intrathoracic pressure pushes mediastinal structures toward the unaffected side, making chest asymmetry a hallmark sign.
D. Blood-tinged sputum: Blood-tinged sputum is more commonly seen with pulmonary infections, trauma to the airway, or pulmonary embolism. It is not a primary manifestation of tension pneumothorax, which is primarily characterized by respiratory distress and unilateral findings.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Severe abdominal pain: Severe abdominal pain is more characteristic of placental abruption, not placenta previa. Placenta previa typically causes painless bleeding rather than acute abdominal pain, so pain is not a primary expected finding.
B. Polyhydramnios: Excess amniotic fluid is unrelated to placenta previa and is associated with conditions like fetal anomalies, maternal diabetes, or multiple gestation. It is not a typical clinical finding in this condition.
C. Spotting: Painless vaginal bleeding, often bright red and intermittent, is the hallmark sign of placenta previa. Spotting or heavier bleeding occurs as the placenta overlies or partially covers the cervical os, especially during the third trimester.
D. Nausea: Nausea is a nonspecific symptom and is not directly associated with placenta previa. It may occur during normal pregnancy but does not indicate the presence of this placental condition.
Correct Answer is D
Explanation
Rationale:
A. Contact: Contact precautions are used for infections transmitted by direct or indirect contact with the client or their environment, such as MRSA or C. difficile. Erythema migrans, associated with Lyme disease, is not spread through contact.
B. Droplet: Droplet precautions are for infections transmitted through large respiratory droplets, such as influenza or pertussis. Lyme disease does not spread via respiratory secretions, so droplet precautions are unnecessary.
C. Airborne: Airborne precautions apply to infections transmitted via small particles that remain suspended in the air, such as tuberculosis or measles. Lyme disease is not airborne, so this precaution is not required.
D. Standard: Standard precautions are appropriate for Lyme disease, including erythema migrans. These precautions involve routine hand hygiene, use of gloves when in contact with body fluids, and proper handling of contaminated materials, which are sufficient since the disease is transmitted via tick bites, not person-to-person.
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