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

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. Assign the AP to ask the client if she has taken her antidiabetic medication today: Asking about medication adherence is part of assessment and requires clinical judgment. Delegating this task to an AP is inappropriate because it involves interpreting client responses and making clinical decisions.

B. Determine if the AP has the skills to perform the test: Before delegating any task, the nurse must verify that the AP is competent and trained to perform the procedure safely. Ensuring skill competency protects the client from harm and aligns with the nurse’s responsibility for delegation.

C. Have the AP check the medical record for prior blood glucose test results: Reviewing medical records and interpreting trends involves clinical judgment and falls outside the typical scope of practice for an AP. This task should remain with the licensed nurse.

D. Help the AP perform the blood glucose test: Assisting the AP is not necessary if the AP is competent and has been properly trained. The nurse’s role is to delegate appropriately, supervise as needed, and ensure safe completion, rather than performing the task alongside the AP.

A. "Why did you start drinking alcohol?" B. "Does anyone else in your family have a drinking problem?" C. "How old were you when you started to drink alcohol?" D. "How often do you drink alcohol?”

Correct Answer is D

Explanation

Rationale:

A. "Why did you start drinking alcohol?": This question explores motivations or personal history but is not part of the standardized Alcohol Use Disorders Identification Test (AUDIT). The AUDIT focuses on quantity, frequency, and consequences of alcohol use rather than reasons for drinking.

B. "Does anyone else in your family have a drinking problem?": Family history of alcohol use may be relevant for overall assessment but is not included in the AUDIT, which is designed to screen the client’s own drinking behaviors and risks.

C. "How old were you when you started to drink alcohol?": Age of initiation provides background information but is not a question within the AUDIT. The test is concerned with current patterns and consequences of alcohol consumption.

D. "How often do you drink alcohol?": This question is a standard component of the AUDIT and assesses the frequency of alcohol consumption. It helps identify patterns of use and potential risk for alcohol-related problems, making it appropriate for inclusion in the screening.

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A nurse is caring for a client who has a tension pneumothorax. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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