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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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Steatorrhea (fatty stools) is not typically associated with pneumonia; it is more commonly linked to gastrointestinal disorders.

B. Tinnitus (ringing in the ears) is not a common symptom of pneumonia but may be related to ear infections or other conditions.

C. Dysphagia (difficulty swallowing) is not typically a hallmark symptom of pneumonia, though it can occur in severe cases if there is aspiration.

D. Fever is a common symptom of bacterial pneumonia due to the body’s response to infection.

A. Place a nonadherent dressing on the right knee abrasion. B. Administer Ibuprofen 200 mg C. Apply ice packs to the fingers and along the right forearm. D. Elevate the affected forearm with pillows. E. Review cast care instructions with the child's parents. F. Explain the cast application procedure to the child.

Correct Answer is ["B","C","D"]

Explanation

A. Place a nonadherent dressing on the right knee abrasion: While minor abrasions should be cleaned and dressed, it is not a priority compared to managing the child's pain and fracture care.

B. Administer Ibuprofen 200 mg: Ibuprofen is an appropriate analgesic and anti-inflammatory medication to manage the child's pain (rated 5/10) and reduce swelling. Prompt pain relief is essential for the child’s comfort.

C. Apply ice packs to the fingers and along the right forearm: Applying ice helps reduce edema, pain, and inflammation at the fracture site. It also minimizes soft tissue damage.

D. Elevate the affected forearm with pillows: Elevating the arm helps reduce swelling and promotes venous return, which is essential for minimizing discomfort and preventing complications like compartment syndrome.

E. Review cast care instructions with the child's parents: Reviewing cast care is essential but should be done after the cast is applied, not at this stage of care.

F. Explain the cast application procedure to the child: This is important but not an immediate priority. The nurse should first address pain, swelling, and proper limb positioning before discussing the procedure.

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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?

Nursing Test Bank

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