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 A
Explanation
Choice A rationale:
Iron supplements Iron supplements are commonly used to treat or prevent iron deficiency anemia. While beneficial in relieving iron deficiency, iron pills can cause side effects like constipation, diarrhea, nausea, vomiting, dark stools, stomach cramps, and a metallic taste. However, constipation is not the primary side effect of iron supplements.
Choice B rationale:
Magnesium-containing antacids Magnesium-containing antacids are used to relieve the symptoms of gastroesophageal reflux disease (GERD), heartburn, or indigestion. By neutralizing stomach acid, antacids relieve symptoms such as burning behind the breast bone or throat area caused by acid reflux, a bitter taste in the mouth, a persistent dry cough, pain when lying down, or regurgitation. While these antacids can cause diarrhea, they do not typically lead to constipation.
Choice C rationale:
Anticholinergics/Antispasmodics Anticholinergics and antispasmodics are used to relieve cramps or spasms of the stomach, intestines, and bladder. Some are used together with antacids or other medicines in the treatment of peptic ulcers. Others are used to prevent nausea, vomiting, and motion sickness. While these medications can cause a variety of side effects, constipation is not a primary side effect.
Choice D rationale:
Opioid narcotics Opioids, also known as narcotics, are a class of drugs healthcare providers prescribe to manage moderate to severe pain, as well as chronic coughing and diarrhea. Common side effects of narcotics include constipation, decreased sweating, dizziness, dry mouth, nose, throat, or skin. Therefore, opioid narcotics are the medication most likely to lead to constipation among the options provided.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
Donning sterile gloves before inserting the indwelling urinary catheter is a standard practice in healthcare to prevent infection. The urinary tract is normally sterile, and the use of sterile gloves helps maintain this sterility during the catheter insertion process. Choice B rationale:
Oil-based lubricants should not be used with indwelling urinary catheters. These lubricants can damage the catheter material and increase the risk of infection. Instead, water-soluble lubricants are recommended as they do not damage the catheter and can reduce patient discomfort during the insertion process.
Choice C rationale:
Testing the balloon on the indwelling urinary catheter before insertion is a critical step. This is done to ensure that the balloon inflates and deflates properly. If the balloon does not function correctly, it could cause discomfort or injury to the patient during insertion and could fail to keep the catheter in place once inserted.
Choice D rationale:
Cleaning the patient’s urinary meatus with one cotton swab is a part of the standard procedure before inserting an indwelling urinary catheter. This step is taken to remove any bacteria present at the site of insertion, thereby reducing the risk of introducing bacteria into the bladder during the catheter insertion.
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