A nurse in the emergency department is caring for a patient who was injured in a motor-vehicle crash. The patient reports dyspnea and severe pain.
The nurse notes that the patient’s chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?

Flail chest

Hemothorax

Atelectasis

Pneumothorax

Answer and Explanation

The Correct Answer is A

Choice A rationale

The symptoms described, including the paradoxical movement of the chest wall (moving inward during inspiration and outward during expiration), are indicative of a flail chest, which is a life-threatening condition that occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall.

Choice B rationale

Hemothorax is a collection of blood in the space between the chest wall and the lung (the pleural cavity). It’s often caused by chest trauma. It does not cause the chest to move inward during inspiration and outward during expiration.

Choice C rationale

Atelectasis is a complete or partial collapse of the entire lung or area (lobe) of the lung. It does not cause the chest to move inward during inspiration and outward during expiration.

Choice D rationale

Pneumothorax is a collapsed lung. It does not cause the chest to move inward during inspiration and outward during expiration.

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Free Nursing Study Resources

Correct Answer is ["120"]

Explanation

The correct answer is 120 gtt/min.

Step 1 is to convert the infusion rate from mL/hr to mL/min: 120 mL/hr ÷ 60 min/hr = 2 mL/min.

Step 2 is to multiply the mL/min rate by the drop factor to find the gtt/min rate: 2 mL/min × 60 gtt/mL = 120 gtt/min.

A. Petechiae B. Nausea C. Cyanosis D. Fever

Correct Answer is B

Explanation

Choice A rationale

Petechiae, or small red or purple spots on the skin caused by minor bleeding from broken capillary blood vessels, are an objective finding. They can be seen and evaluated by the nurse during a physical examination.

Choice B rationale

Nausea is a subjective symptom. It is something the patient experiences and reports, but it cannot be directly observed or measured by the nurse.

Choice C rationale

Cyanosis, or bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is an objective finding. It can be observed by the nurse during a physical examination.

Choice D rationale

Fever is an objective finding. It can be measured by the nurse using a thermometer.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["120"]

Explanation

A nurse is conducting a patient’s history and physical examination. Which information should the nurse consider as subjective data?

Correct Answer is B

Explanation

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