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 ["A","D","F"]

Explanation

Rationale:

A. Monitor the height and tone of the client's fundus: Assessing uterine fundus is essential postpartum, especially with signs of infection and moderate lochia. Monitoring for firmness, height, and consistency helps identify uterine atony or worsening infection, guiding timely interventions to prevent hemorrhage or complications.

B. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics prescribed for postpartum infections, such as clindamycin, are considered compatible with breastfeeding. Advising formula feeding unnecessarily could disrupt breastfeeding without clinical justification.

C. Initiate contact precautions: Postpartum infections like endometritis or mastitis are generally not spread via contact in a hospital setting. Standard precautions, including hand hygiene, are sufficient unless a specific transmissible pathogen is identified.

D. Instruct the client to wash her hands before and after changing her perineal pad: Hand hygiene prevents the spread of infection and reduces the risk of secondary infections. Teaching proper handwashing is an essential standard precaution for clients with postpartum infections.

E. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: Routine cultures of lochia are not indicated unless there is suspicion of an unusual pathogen or worsening infection. Assessment and empiric antibiotics are standard for postpartum endometritis based on clinical findings.

F. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Semi-Fowler’s positioning promotes uterine drainage, reduces stasis of lochia, and supports comfort. This position aids in preventing complications such as uterine infection or retention of lochia.

G. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to suppress preterm labor. It is not indicated for postpartum infection, uterine atony, or lochia management and is not appropriate in this scenario.

Correct Answer is ["2.5"]

Explanation

Calculation:

Identify the ordered dose and available concentration

Ordered Dose: 20 mg

Available Concentration: 40 mg/5 mL

Calculate the volume to administer

Volume to administer = (Ordered Dose ÷ Concentration) × Volume of Concentration

Volume to administer = (20 ÷ 40) × 5

Volume to administer = 0.5 × 5

Volume to administer = 2.5 mL

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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

A nurse on a postpartum unit is caring for a client. Exhibits The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","D","F"]

Explanation

Correct Answer is ["2.5"]

Explanation

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