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 A
Explanation
Choice A reason: Caffeinated beverages can cause diarrhea by stimulating the intestinal motility and increasing the fluid loss. They can also irritate the lining of the stomach and intestines.
Choice B reason: Low-fiber cereal is not likely to cause diarrhea. Fiber helps to bulk up the stool and regulate the bowel movements. Low-fiber foods are often recommended for clients with diarrhea to reduce intestinal activity.
Choice C reason: White rice is not likely to cause diarrhea. It is a bland and starchy food that can help to bind the stool and reduce fluid loss. White rice is often part of the BRAT diet (bananas, rice, applesauce, toast) that is suggested for clients with diarrhea.
Choice D reason: Ripe bananas are not likely to cause diarrhea. They are rich in potassium, which can help to replenish the electrolytes lost due to diarrhea. They also contain pectin, a soluble fiber that can help to firm up the stool.
Correct Answer is B
Explanation
Choice A reason: Doing wheelchair exercises sitting in the chair is a correct statement, as it helps to prevent pressure ulcers, improve circulation, and maintain muscle tone.
Choice B reason: Using a suppository every night to have a bowel movement is an incorrect statement, as it indicates a dependence on laxatives and a lack of bowel training. The adolescent should be taught to establish a regular bowel routine, use natural methods such as abdominal massage and digital stimulation, and avoid overuse of laxatives.
Choice C reason: Needing to catheterize oneself twice a day is a correct statement, as it helps to prevent urinary tract infections, bladder distension, and kidney damage.
Choice D reason: Carrying a water bottle with me because I drink a lot of water is a correct statement, as it helps to prevent dehydration, constipation, and urinary tract infections.
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