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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. Palpate the uterus for contractions: Assessing uterine activity is important after a seizure to monitor for labor or fetal compromise, but it does not address the immediate risk of maternal hypoxia following a seizure. This assessment can be performed after ensuring adequate oxygenation.

B. Administer oxygen 10 L/min via nonrebreather mask: After a seizure, the client is at risk for hypoxia due to apnea or increased oxygen demand. Administering high-flow oxygen is the priority action to restore oxygenation, support maternal and fetal perfusion, and prevent further complications.

C. Observe for post-convulsion incontinence: Monitoring for incontinence helps assess seizure severity and patient safety, but it does not immediately correct the critical issue of hypoxia. Observation is secondary to interventions that maintain airway and oxygenation.

D. Provide a quiet environment: Reducing stimuli can help prevent additional seizures or stress, but it is not the first priority after a seizure. Ensuring airway patency and oxygen delivery takes precedence over environmental modifications.

A. Bradypnea B. Sedation C. Constipation D. Euphoria

Correct Answer is A

Explanation

Rationale:

A. Bradypnea: Respiratory depression is the most serious and potentially life-threatening adverse effect of morphine, especially after IV administration when onset is rapid. Bradypnea indicates a compromised airway and inadequate ventilation, making it the nurse’s priority for immediate assessment and intervention to prevent hypoxia and respiratory arrest.

B. Sedation: Sedation is a common effect of morphine and requires monitoring, but it is less immediately dangerous than respiratory depression. The nurse should assess the depth of sedation and level of consciousness while ensuring airway safety.

C. Constipation: Constipation is a common long-term side effect of opioids, but it is not an immediate threat to life. Preventive measures can be planned, but it does not take priority over acute respiratory compromise.

D. Euphoria: Euphoria may occur with opioid administration and is generally not harmful in the short term. While the nurse should monitor for behavioral changes or signs of misuse, it does not pose an immediate risk compared with respiratory depression.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Body system	Findings
Neurologic	Client is awake, alert, oriented x3
Cardiovascular	Client reports no palpitations, heart rhythm regular. Right lower extremity +2 edema from ankle to below the knee joint. Skin warm and inflamed: +2 pedal pulses present in bilateral extremities
Musculoskeletal	Client reports no groin pain, has slight limp with weight bearing on the right extremity

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

A nurse observes a client who is at 37 weeks of gestation and has preeclampsia with severe features having a seizure. Which of the following actions following the seizure should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

Exhibits A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply)

A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first?

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?

A nurse is preparing to administer a subcutaneous injection to a client. Which of the following sites should the nurse choose?

A charge nurse delegates to an assistive personnel (AP) the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first?

A nurse is assessing a client who has obsessive-compulsive personality disorder. Which of the following manifestations should the nurse expect?