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 B
Explanation
Rationale:
A. Hypotension: While hypotension can indicate shock or fluid imbalance, it may develop secondary to other complications. It is concerning but not necessarily the earliest indicator of an acute pulmonary embolism.
B. Dyspnea: Sudden or worsening shortness of breath is the most immediate sign of a possible pulmonary embolism, which is life-threatening. Prompt recognition and reporting are critical to initiate interventions such as oxygen therapy, anticoagulation, or advanced imaging.
C. Dry cough: A dry cough may accompany a pulmonary embolism but is nonspecific and less urgent. It does not indicate immediate compromise compared with respiratory distress or hypoxia.
D. Tachycardia: Elevated heart rate can be an early sign of stress or hypoxia but is less specific than dyspnea. Tachycardia warrants monitoring, but shortness of breath takes priority for immediate action.
Correct Answer is C
Explanation
Rationale:
A. Naloxone: Naloxone is an opioid antagonist used to reverse opioid overdose. It does not provide pain relief and is not appropriate for managing acute exacerbations of chronic pain.
B. Acetaminophen: Acetaminophen is useful for mild to moderate pain but may be insufficient for an acute exacerbation of chronic pain, especially if the client has severe or breakthrough pain.
C. Fentanyl: Fentanyl is a potent opioid analgesic appropriate for managing severe acute pain or acute exacerbations of chronic pain. It acts rapidly to relieve pain and is often used in clients already tolerant to opioids.
D. Zolpidem: Zolpidem is a sedative-hypnotic used to treat insomnia. It does not have analgesic properties and is not indicated for pain management.
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