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
The correct answer is B. Decreased deep tendon reflexes. Hyperkalemia can lead to muscle weakness and decreased reflexes, which is a common manifestation in patients with chronic kidney disease.
Choice A reason:
Wheezing is typically associated with respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD), not hyperkalemia. Hyperkalemia affects the muscular function and cardiac conduction rather than causing respiratory symptoms.
Choice B reason:
Decreased deep tendon reflexes occur due to the effect of hyperkalemia on the neuromuscular junction and muscle excitability. In hyperkalemia, the resting membrane potential of muscle cells is less negative, which makes them less responsive to stimuli.
Choice C reason:
Hypoactive bowel sounds are generally associated with gastrointestinal issues and are not a direct manifestation of hyperkalemia. While severe hyperkalemia can affect smooth muscle function, it is not typically characterized by changes in bowel sounds.
Choice D reason:
Cerebral edema is not a manifestation of hyperkalemia. It is usually caused by traumatic brain injury, infections, or other neurological conditions. Hyperkalemia primarily affects muscular function and cardiac conduction.
Normal serum potassium levels range from about 3.5 to 5.0 mmol/L. Hyperkalemia is defined as serum potassium levels above 5.0 mmol/L.
Correct Answer is D
Explanation
Choice A reason: Reflex incontinence is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs when the bladder is overfilled and the sphincter relaxes. Reflex incontinence can be managed by following a regular catheterization schedule, not by waiting for symptoms.
Choice B reason: Urge incontinence is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs when the bladder contracts involuntarily and the sphincter cannot prevent leakage. Urge incontinence can be managed by using anticholinergic medications, bladder training, or pelvic floor exercises, not by catheterization.
Choice C reason: Nocturnal enuresis is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs during sleep. Nocturnal enuresis can be managed by limiting fluid intake before bedtime, using an alarm device, or taking desmopressin, not by catheterization.
Choice D reason: Suprapubic discomfort is a sign of the need to catheterize the client, as it indicates bladder distension and possible urinary retention. Suprapubic discomfort can be relieved by draining the urine from the bladder using a catheter.
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