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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale
Auscultating the lungs for the presence of breath sounds is a priority action following endotracheal intubation. This helps to confirm correct tube placement and assess for complications such as a pneumothorax.
Choice B rationale
While it is important to ensure that the pulse oximetry is greater than 95% to confirm adequate oxygenation, this is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Choice C rationale
Assessing the baseline level of consciousness is important, but it is not the priority action following endotracheal intubation.
Choice D rationale
Assessing for the presence of circumoral cyanosis can indicate hypoxia, but it is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.

A. “Don’t be too hard on yourself. It’s uncertain if your smoking led to the cancer.”. B. “It’s normal to feel scared. What aspects of cancer frighten you the most?” C. “Do you feel guilty because you used to smoke?” D. “Fear is a normal reaction. We are here to support you through this.”. .

Correct Answer is B

Explanation

Choice A rationale
While it’s important to reassure the patient, saying “It’s uncertain if your smoking led to the cancer” might be misleading. Smoking is a major risk factor for lung cancer, but it’s also true that not everyone who smokes gets lung cancer, and not everyone who gets lung cancer has smoked.
Choice B rationale
This response validates the patient’s feelings and opens up a dialogue about their specific fears. It allows the nurse to provide targeted education and reassurance.
Choice C rationale
Asking “Do you feel guilty because you used to smoke?” might make the patient feel more guilty or judged. It’s better to provide support and understanding.
Choice D rationale
While it’s true that fear is a normal reaction and that the healthcare team is there to support the patient, this response doesn’t address the patient’s specific concerns or feelings of guilt.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient immediately following endotracheal intubation. Which of the following actions should the nurse prioritize to assess the patient for complications?

Correct Answer is A

Explanation

A patient with lung cancer confides in the nurse, expressing fear about the disease and guilt for smoking in the past. Which response from the nurse would be most appropriate?

Correct Answer is B

Explanation

A nurse is providing education to a client diagnosed with Obstructive Sleep Apnea (OSA). Which of the following signs and symptoms of OSA should the nurse include in the education? Select all that apply.

A nurse is caring for a client diagnosed with adult respiratory distress syndrome (ARDS) and being treated with positive end expiratory pressure (PEEP). How does PEEP benefit the client?

A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which precaution should the nurse prioritize when administering nasal oxygen therapy to the client?

A nurse is caring for a patient who reports experiencing an alteration in sense of smell following surgery for a total laryngectomy. The nurse should address the patient’s concern through which of the following responses?

A new graduate nurse attends a seminar on Communication in Healthcare. Which of the following are considered barriers to appropriate communication with clients? Select all that apply.

A nurse is caring for a client newly diagnosed with a pulmonary embolism (PE). Which of the following is the initial assessment finding in the client diagnosed with PE?

A nurse is caring for a client who has a tracheostomy. Based on the Nurses Notes and Diagnostic Results, which of the following is a manifestation in the client?

A nurse is reviewing incident reports submitted during the previous month. The nurse should identify which of the following as a problem that should be reported to the risk manager?