A nurse is collecting data on a client who has a pleural effusion. Which of the following findings should the nurse expect?

Crackles auscultated over the client's lung fields

Crepitus palpated on the client's chest

Substernal retractions noted on the client's chest

Dullness percussed over the client's lung fields

Answer and Explanation

The Correct Answer is D

Choice A reason: Crackles auscultated over the client's lung fields are not a sign of pleural effusion. Crackles are abnormal breath sounds that indicate fluid or secretions in the alveoli. They can be heard in conditions such as pneumonia, heart failure, or pulmonary edema.

Choice B reason: Crepitus palpated on the client's chest is not a sign of pleural effusion. Crepitus is a crackling sensation that occurs when air leaks into the subcutaneous tissue. It can be felt in conditions such as pneumothorax, chest trauma, or chest surgery.

Choice C reason: Substernal retractions noted on the client's chest are not a sign of pleural effusion. Substernal retractions are inward movements of the chest wall below the sternum that indicate increased respiratory effort. They can be seen in conditions such as asthma, bronchiolitis, or croup.

Choice D reason: Dullness percussed over the client's lung fields is a sign of pleural effusion. Dullness is a flat sound that indicates the presence of a solid or liquid mass in the thoracic cavity. It can be detected in conditions such as pleural effusion, atelectasis, or consolidation.

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Correct Answer is D

Explanation

Choice A reason: Prone is not the best position to allow maximal lung expansion. Prone is a position where the client lies on their stomach, with their head turned to one side. Prone can help to improve oxygenation in some cases of acute respiratory distress syndrome (ARDS), but it can also increase the risk of pressure ulcers, facial edema, and airway obstruction.

Choice B reason: Side-lying is not the best position to allow maximal lung expansion. Side-lying is a position where the client lies on their side, with their head supported by a pillow. Side-lying can help to prevent aspiration and reduce the work of breathing in some clients, but it can also compromise the ventilation of the dependent lung.

Choice C reason: Supine is not the best position to allow maximal lung expansion. Supine is a position where the client lies on their back, with their head and shoulders slightly elevated. Supine can help to maintain a patent airway and facilitate suctioning in some clients, but it can also increase the risk of atelectasis, pneumonia, and hypoxemia.

Choice D reason: Upright is the best position to allow maximal lung expansion. Upright is a position where the client sits or stands with their back straight and their chest expanded. Upright can help to improve lung compliance, reduce airway resistance, and enhance gas exchange in clients with respiratory failure. Upright can also reduce the pressure on the diaphragm and abdominal organs, and promote the drainage of secretions.

A. The pulse oximeter might not be accurate during times of excessive movement. B. We will notify the doctor if the pulse oximeter consistently reads 100%. C. The probe of the pulse oximeter can be applied to a finger or a toe. D. We will rotate the probe of the pulse oximeter every 24 hours.

Correct Answer is B

Explanation

Choice A reason: The pulse oximeter might not be accurate during times of excessive movement is a correct statement, as movement can interfere with the detection of the pulse and the oxygen saturation. The parents should try to keep the infant still and calm while using the pulse oximeter.

Choice B reason: We will notify the doctor if the pulse oximeter consistently reads 100% is an incorrect statement, as it indicates a misunderstanding of the normal range of oxygen saturation. The parents should not be alarmed if the pulse oximeter reads 100%, as it means that the infant's blood is fully saturated with oxygen. The normal range of oxygen saturation for infants is 95% to 100%.

Choice C reason: The probe of the pulse oximeter can be applied to a finger or a toe is a correct statement, as these are suitable sites for measuring the oxygen saturation in infants. The parents should make sure that the probe fits snugly and securely on the infant's finger or toe.

Choice D reason: We will rotate the probe of the pulse oximeter every 24 hours is a correct statement, as it helps to prevent skin irritation, pressure ulcers, or infection from prolonged contact with the probe. The parents should also check the infant's skin regularly for any signs of redness, swelling, or pain.

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A nurse is collecting data on a client who has a pleural effusion. Which of the following findings should the nurse expect?

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