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 B
Explanation
Choice A rationale
Reports routinely listing the identification number of any equipment involved is not a problem. This is a standard practice in incident reporting as it helps in identifying and tracking the equipment involved in the incident.
Choice B rationale
Reports routinely omitting the names of witnesses to the occurrence is a problem that should be reported to the risk manager. Witnesses can provide crucial information about the incident, and their statements can help in understanding the sequence of events and identifying the root cause of the incident.
Choice C rationale
Reports being completed within 24 hours after the incident is not a problem. Timely reporting of incidents is crucial for accurate recall of events and immediate initiation of corrective actions.
Choice D rationale
Reports routinely including the client’s hospital number is not a problem. This is a standard practice in incident reporting as it helps in identifying and tracking the patient involved in the incident.
Correct Answer is A
Explanation
Choice A rationale
In a client diagnosed with chronic obstructive pulmonary disease (COPD), an arterial blood gas (ABG) test would typically show an increased level of carbon dioxide (PaCO2)56. This is because COPD affects the ability of the lungs to expel carbon dioxide, leading to its buildup in the blood.
Choice B rationale
An increased pH is not typically seen in COPD. In fact, due to the increased carbon dioxide (which is acidic), the pH may be lower, indicating respiratory acidosis.
Choice C rationale
Decreased alveolar function is a characteristic of COPD, but it is not something that would be directly measured in an ABG test.
Choice D rationale
An increased arterial oxygen (PaO2) is not typically seen in COPD. In fact, due to the impaired gas exchange, PaO2 may be lower.
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