A nurse is providing care for a client following a thoracentesis. If the client develops a pneumothorax, which of the following assessment findings should the nurse expect?
Pain on inhalation
Bradycardia
Friction rub
Stridor
The Correct Answer is A
A. Pain on inhalation is a common symptom of pneumothorax due to pleural irritation and collapse of the lung.
B. Tachycardia, not bradycardia, is more likely in a client with a pneumothorax due to hypoxia.
C. A friction rub is associated with pleuritis, not pneumothorax.
D. Stridor is a sign of upper airway obstruction, not pneumothorax.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increased pain: Naloxone is an opioid antagonist and will reverse the analgesic effects of the opioid, likely leading to increased pain in the client.
B. Hyperglycemia: Incorrect. Naloxone does not typically cause changes in glucose metabolism.
C. Hypoventilation: Incorrect. Naloxone reverses respiratory depression, so hypoventilation is not expected after its administration.
D. Somnolence: Incorrect. Naloxone should reverse somnolence caused by opioids, leading to more alertness.
Correct Answer is ["A","B","C","E","F"]
Explanation
A. Exert upward pressure on the presenting part. If there are signs of cord prolapse or pressure on the umbilical cord, exerting upward pressure on the presenting part can relieve compression. This action helps maintain blood flow and oxygen supply to the fetus.
B. Place the client in a Trendelenburg position. Positioning the client with the pelvis elevated higher than the head can reduce pressure on the umbilical cord if prolapse is suspected or confirmed. This promotes fetal circulation and decreases the risk of hypoxia.
C. Administer oxygen at 10 L/min via nonrebreather face mask. Administering high-flow oxygen increases maternal oxygenation, which in turn improves oxygen delivery to the fetus. This is a priority intervention to ensure fetal well-being during labor.
D. Attempt to push the umbilical cord back into the cervix. This is incorrect because pushing the cord back into the cervix is contraindicated due to the risk of damaging the cord or introducing infection. Other measures, such as repositioning and elevating the presenting part, should be prioritized instead.
E. Have the charge nurse notify the provider. Timely communication with the provider is critical when complications arise during labor, such as suspected umbilical cord prolapse. The provider may need to intervene urgently, possibly requiring an emergency cesarean section.
F. Increase the flow rate of the maintenance IV fluid. Increasing the IV fluid rate helps improve maternal circulation and blood flow to the uterus and placenta, ensuring the fetus receives adequate oxygen and nutrients. This is a supportive measure during labor when complications arise.
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