A nurse is gathering information on a patient who has pleural effusion.
What symptoms should the nurse anticipate?
Crackles heard over the patient’s lung fields.
Crepitus felt on the patient’s chest.
Substernal retractions observed on the patient’s chest.
Dullness heard when percussing the patient’s lung fields.
Correct Answer : A,D
Choice A rationale:
Crackles are a common symptom of pleural effusion. They are abnormal lung sounds that are heard when a patient with pleural effusion breathes in. The sound is caused by the opening of small airways and alveoli collapsed by fluid, exudate, or lack of aeration during expiration.
Choice B rationale:
Crepitus is not typically associated with pleural effusion. Crepitus is a crackling or grating sound or feeling produced by air in subcutaneous tissue or by the rubbing together of fragments of broken bone. In the context of respiratory health, crepitus might be felt if there is subcutaneous emphysema, where air gets into tissues under the skin covering the chest wall or neck.
Choice C rationale:
Substernal retractions are not a typical symptom of pleural effusion. Retractions are a sign of respiratory distress, but they are more commonly associated with conditions that cause upper airway obstruction or severe lung disease, such as asthma or pneumonia. Choice D rationale:
Dullness upon percussion is a classic sign of pleural effusion. When there is fluid in the pleural space, it prevents the normal resonant sound produced by the air-filled lungs from being heard. Instead, a dull sound is heard when the chest is percussed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Reflex incontinence is a type of urinary incontinence that occurs when the person has no control over urination. They’re unable to feel when their bladder is full and can’t control the process of emptying it. This is often due to a brain or spinal cord injury that disrupts communication between these organs. However, this condition does not necessarily indicate the need for catheterization in a client with paraplegia who is already on an intermittent urinary catheterization program.
Choice B rationale:
Urge incontinence, also known as overactive bladder, is characterized by a sudden, intense urge to urinate, followed by an involuntary loss of urine. This condition can be caused by various factors, including neurological disorders, bladder abnormalities, and certain medications. While it can be a challenge for individuals with paraplegia, it does not directly indicate the need for catheterization.
Choice C rationale:
Nocturnal enuresis, or bedwetting, is involuntary urination while asleep. It’s a common condition, especially in young children, but it can affect individuals of any age. In the context of a client with paraplegia, nocturnal enuresis could be a symptom of a larger issue, such as a urinary tract infection or bladder dysfunction, but it does not directly indicate the need for catheterization. Choice D rationale:
Suprapubic discomfort or pain in the area above the pubic bone could be a sign of bladder distension, which is a common complication in individuals with spinal cord injuries. Bladder distension can occur when the bladder becomes overly full and can’t empty, causing discomfort or pain in the lower abdomen. This is a clear indication for the need to catheterize the client.
Correct Answer is B
Explanation
Choice A rationale:
A respiratory rate of 28/min is not an indication that the intervention was effective. A normal respiratory rate for an adult at rest is between 12 and 20 breaths per minute. A respiratory rate of 28/min is considered tachypnea, which could be a sign of respiratory distress, not an improvement.
Choice B rationale:
Pink mucous membranes are a good sign. They indicate effective oxygenation and perfusion. When the body is receiving an adequate amount of oxygen, the skin, lips, and mucous membranes can appear pink. This is a positive outcome of oxygen therapy for hypoxia.
Choice C rationale:
A heart rate of 110/min is not an indication that the intervention was effective. A normal resting heart rate for adults ranges from 60 to 100 beats per minute. A heart rate of 110/min is considered tachycardia, which could be a sign of distress or compensation for hypoxia, not an improvement.
Choice D rationale:
Restlessness is not an indication that the intervention was effective. On the contrary, restlessness can be a sign of inadequate oxygenation. When the brain does not receive enough oxygen, a patient can become restless or anxious. Therefore, restlessness is not a positive outcome of oxygen therapy for hypoxia.
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