During a central IV line insertion at the bedside, a client reports shortness of breath and becomes tachypneic. Which finding should a nurse suspect indicates the client developed a pneumothorax?
Muffled heart sounds.
Sudden hemoptysis.
Absent breath sounds on the affected side.
Declining respiratory rate.
The Correct Answer is C
Choice A rationale
Muffled heart sounds are not a typical sign of pneumothorax. They are more commonly associated with conditions such as pericardial effusion or cardiac tamponade.
Choice B rationale
Sudden hemoptysis, or coughing up blood, is not a typical sign of pneumothorax. It is more commonly associated with conditions such as pulmonary embolism or lung cancer.
Choice C rationale
Absent breath sounds on the affected side is a typical sign of pneumothorax. When air enters the pleural space and causes the lung to collapse, breath sounds may be absent or significantly decreased on the affected side.
Choice D rationale
A declining respiratory rate is not a typical sign of pneumothorax. In fact, a rapid respiratory rate (tachypnea) is more commonly observed in pneumothorax due to the body’s attempt to compensate for the decreased lung capacity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Following ventilator-weaning protocols is an important intervention to prevent ventilator-associated pneumonia. Weaning protocols help to reduce the duration of mechanical ventilation, which is a risk factor for developing ventilator-associated pneumonia.
Choice B rationale
Providing frequent mouth care is a key intervention in preventing ventilator-associated pneumonia. Good oral hygiene can help to reduce the amount of bacteria in the mouth that can potentially be aspirated into the lungs.
Choice C rationale
Suctioning the patient every hour is not typically recommended as a method to prevent ventilator-associated pneumonia. Over-suctioning can potentially damage the lung tissue and mucous membranes, and it can also increase the risk of introducing bacteria into the lungs.
Choice D rationale
Placing the patient in a prone position can help to improve oxygenation and reduce the risk of ventilator-associated pneumonia. The prone position can help to drain secretions from the lungs, reducing the risk of bacteria growth and infection.
Choice E rationale
Refraining from suctioning the patient is not a recommended intervention to prevent ventilator-associated pneumonia. Suctioning is necessary to remove secretions from the airway, which can help to prevent infection.
Correct Answer is A
Explanation
Choice A rationale
This situation represents an ethical conflict. The nurse is faced with a dilemma where the children’s wishes for their parent to be a full code contradict the client’s expressed wish in their living will for Do Not Resuscitate (DNR)2. Ethical conflicts often arise in healthcare when there are differing opinions about the right course of action.
Choice B rationale
Scarcity, safety, and security are not the primary sources of conflict in this situation. While these factors can contribute to conflict in certain contexts, they do not directly apply to the ethical dilemma presented in this scenario.
Choice C rationale
Competition between groups is not evident in this situation. The conflict arises from differing views on the appropriate course of action for the client’s care, not from competition.
Choice D rationale
Cultural differences are not the main source of conflict in this scenario. The conflict arises from an ethical issue related to the client’s end-of-life care, not from cultural differences.
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