A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

Choice A rationale:

Asthma - Asthma is a chronic respiratory condition characterized by bronchoconstriction, inflammation, and increased mucus production. It does not typically present with absent breath sounds, deviation of the trachea, or hyperresonant percussion sounds. Wheezing is a common finding in asthma.

Choice B rationale:

Pneumothorax - This is the correct choice. The scenario describes classic signs of a tension pneumothorax, which is a medical emergency. The tracheal deviation, absence of breath sounds, and hyperresonant percussion note on the affected side are indicative of air accumulation in the pleural space, leading to lung collapse and displacement of mediastinal structures.

Choice C rationale:

Atelectasis - Atelectasis refers to the collapse or incomplete expansion of a lung or part of a lung. It can lead to decreased breath sounds on auscultation but does not usually cause tracheal deviation or hyperresonance on percussion. It is not the best fit for the described signs.

Choice D rationale:

Pneumonia - Pneumonia is an infection of the lung tissue that can cause symptoms like fever, cough, and productive sputum. Breath sounds may be diminished over the affected area due to consolidation, but the absence of breath sounds, tracheal deviation, and hyperresonance point more strongly toward a pneumothorax in this case.

Choice A rationale:

Visual observation for nonverbal signs of pain can be useful, especially in patients who are unable to communicate verbally. However, this method is not as accurate or reliable as obtaining the client's self-report of pain severity, which directly allows the patient to express their experience.

Choice B rationale:

Vital sign measurement, such as heart rate, blood pressure, and respiratory rate, can provide indirect information about a patient's pain level. However, vital signs can be influenced by various factors, including anxiety or other physiological responses. They may not always accurately reflect the intensity of pain and are not as specific as the client's self-report.

Choice C rationale:

The client's self-report of pain severity is the most reliable and accurate method for determining the intensity of pain. Pain is a subjective experience, and the client's self-report is crucial for effective pain management. Pain scales, such as numeric rating scales or visual analog scales, allow clients to describe their pain intensity in a standardized way.

Choice D rationale:

The nature and invasiveness of the surgical procedure are relevant factors to consider in understanding a patient's potential pain experience. However, this information alone is not sufficient for determining the current intensity of the client's pain. Pain levels can vary among individuals undergoing the same procedure due to differences in pain tolerance and perception.