A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax?

Diminished breath sounds

Distended neck veins

Irregular heart rate

Itching over the incision

Answer and Explanation

The Correct Answer is A

A. Diminished breath sounds: A pneumothorax occurs when air accumulates in the pleural space, leading to lung collapse. This results in reduced air entry, causing diminished or absent breath sounds on the affected side. Other symptoms may include dyspnea, tachypnea, and chest pain.

B. Distended neck veins: Neck vein distention is more commonly associated with conditions such as cardiac tamponade or superior vena cava syndrome. A pneumothorax typically causes respiratory distress rather than venous congestion. If a tension pneumothorax develops, neck vein distention may occur, but it is not an early or primary sign.

C. Irregular heart rate: While severe cases of pneumothorax can cause cardiovascular compromise due to pressure on the heart and great vessels, an irregular heart rate is not a direct or early indicator. Cardiac arrhythmias are more often seen with electrolyte imbalances, cardiac ischemia, or other primary heart conditions.

D. Itching over the incision: Itching at the catheter insertion site is a common postoperative reaction, often related to healing, adhesive irritation, or mild inflammation. It is not indicative of a pneumothorax, which primarily presents with respiratory distress and absent or diminished breath sounds.

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Correct Answer is A

Explanation

A. Apply an ice pack to the client's knee: Ice application helps reduce pain and inflammation by decreasing swelling around the surgical site. Cold therapy also numbs nerve endings, providing pain relief for clients after knee arthroplasty.

B. Place pillows under the client's knee: Elevating the knee with pillows can promote flexion contractures and is generally avoided after knee arthroplasty. Instead, the leg should be kept extended and supported to encourage proper alignment and prevent complications.

C. Perform range-of-motion exercises to the client's knee: While range-of-motion exercises are important for rehabilitation, they should be done at scheduled times and not during episodes of acute pain, as they could exacerbate discomfort.

D. Gently massage the area around the client's incision: Massaging near the incision site is not recommended, as it could disrupt healing tissue, increase pain, and pose a risk of infection.

A. Blood pressure 108/62 mm Hg B. Potassium 3.5 mEq/L (3.5 to 5 mEq/L) C. Frequent, nonproductive cough D. Frequent, painless urination

Correct Answer is C

Explanation

A. Blood pressure 108/62 mm Hg: Lisinopril is an antihypertensive, and a systolic BP above 90 mm Hg is typically not considered an adverse effect. Hypotension can occur but is more concerning if it results in symptoms such as dizziness or syncope.

B. Potassium 3.5 mEq/L (3.5 to 5 mEq/L): Lisinopril can cause hyperkalemia, but a potassium level of 3.5 mEq/L is within the normal range. Monitoring potassium levels is essential, but this finding does not indicate an adverse effect.

C. Frequent, nonproductive cough: A dry, persistent cough is a common adverse effect of lisinopril due to the accumulation of bradykinin. It often does not resolve until the medication is discontinued or switched to an alternative, such as an angiotensin receptor blocker (ARB).

D. Frequent, painless urination: Lisinopril does not typically cause increased urination. While it affects renal function, it is more likely to lead to hyperkalemia or reduced glomerular filtration rate in susceptible individuals.

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A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax?

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