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 B
Explanation
A. "I will monitor the client’s blood glucose level every 8 hours": Incorrect. Blood glucose should be monitored more frequently, typically every 4-6 hours, due to the risk of hyperglycemia.
B. "I will hang a new bag of TPN and IV tubing every 24 hours": This practice reduces the risk of infection associated with TPN, which is a high-risk therapy.
C. "I will increase the rate of the TPN infusion to ensure the correct amount is given": Incorrect. The TPN infusion rate should not be adjusted without a provider's order, as it can cause hyperglycemia or fluid overload.
D. "I will obtain the client’s weight every other day": Incorrect. Daily weights are necessary to monitor fluid status and nutritional effectiveness.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
Finding |
Improved |
Not changed |
Heart rate |
✓ |
|
Blood pressure |
✓ |
|
Edema |
✓ |
|
Deep tendon reflexes |
✓ |
Rationale
- Heart rate: Not changed
- The heart rate increased from 72/min to 90/min, indicating no improvement.
- Blood pressure: Improved
- The blood pressure decreased from 166/110 mm Hg to 152/90 mm Hg, indicating improvement.
- Edema: Improved
- The edema decreased from +3 pitting to +2 pitting, indicating improvement.
- Deep tendon reflexes: Improved
- The patellar reflex decreased from 4+ to 2+, indicating improvement.
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