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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Requesting that the provider prescribe a stool softener is not the best action for the nurse to take, as it may cause dependency, dehydration, or electrolyte imbalance. The nurse should try non-pharmacological interventions first, such as increasing fluid and fiber intake, promoting physical activity, and establishing a regular bowel routine.
Choice B reason: Adding fluid and fiber to the diet is the best action for the nurse to take, as it helps to soften the stool, increase the bulk, and stimulate peristalsis. The nurse should encourage the client to drink at least 2 liters of water per day and eat foods rich in fiber, such as fruits, vegetables, and whole grains.
Choice C reason: Promoting active range-of-motion activities is a good action for the nurse to take, as it helps to improve circulation, muscle tone, and bowel motility. The nurse should assist the client to perform exercises that are appropriate for their level of mobility and endurance.
Choice D reason: Avoiding gas-producing foods is not a necessary action for the nurse to take, as it does not directly affect constipation. Gas-producing foods, such as beans, cabbage, and broccoli, may cause bloating and discomfort, but they do not cause or worsen constipation.
Correct Answer is A
Explanation
Choice A reason: Muscle twitching is a sign of central nervous system oxygen toxicity, which can occur when breathing high concentrations of oxygen under pressure. It can also cause seizures, confusion, and loss of consciousness.
Choice B reason: Facial flushing is not a symptom of oxygen toxicity. It can be caused by other conditions such as fever, allergic reactions, or alcohol consumption.
Choice C reason: Periorbital edema is not a symptom of oxygen toxicity. It can be caused by other conditions such as kidney disease, heart failure, or allergies.
Choice D reason: Metallic taste in mouth is not a symptom of oxygen toxicity. It can be caused by other conditions such as medication side effects, dental problems, or infections.
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