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:
Circulatory overload, also known as hypervolemia or fluid overload, is a condition where the body has too much fluid. This excess fluid, especially in the circulatory system, can lead to a rapid heartbeat. This is because the heart needs to work harder to pump the increased volume of blood, leading to an increased heart rate.
Choice B rationale:
Weight loss is not typically associated with circulatory overload. In fact, quick weight gain might be observed due to the excess fluid in the body.
Choice C rationale:
Low blood pressure is not a common symptom of circulatory overload. On the contrary, high blood pressure can occur because the excess fluid in the circulatory system puts more pressure on the blood vessel walls.
Choice D rationale:
Excessive sweating is not a direct symptom of circulatory overload. However, symptoms such as shortness of breath and swelling in certain areas of the body are more common.
Correct Answer is C
Explanation
Choice A rationale:
Hypertension is not typically a sign of hypokalemia. Hypokalemia, or low potassium levels, can cause symptoms like fatigue, muscle weakness, digestive problems, and frequent urination. Hypertension, or high blood pressure, is not commonly associated with hypokalemia.
Choice B rationale:
Cerebral edema, or swelling in the brain, is not a common symptom of hypokalemia. Hypokalemia is more likely to cause symptoms related to muscle function and digestion, as potassium is an essential mineral that helps regulate muscle contractions, maintain healthy nerve function, and regulate fluid balance.
Choice C rationale:
Muscle weakness is a common symptom of hypokalemia. Potassium helps regulate muscle contractions. When blood potassium levels are low, your muscles produce weaker contractions. This can result in symptoms like muscle weakness and fatigue.
Choice D rationale:
Hyperactive bowel sounds are not typically associated with hypokalemia. Hypokalemia can cause digestive problems, but these are more likely to be issues like constipation rather than increased bowel sounds.
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