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 B

Explanation

A. Closing the inline clamp is necessary when the catheter is not in use to prevent air embolism, but it is not a required step before administering medication. The nurse should focus on flushing and checking for patency before medication administration.

B. Flushing the catheter with 10 mL of 0.9% sodium chloride before and after medication administration helps maintain patency, prevents occlusion, and ensures the catheter is functioning properly. This step is essential to avoid complications such as clot formation.

C. Applying a local anesthetic is not needed for routine medication administration through a nontunneled percutaneous central catheter. Anesthetic use is typically reserved for procedures like catheter insertion or painful dressing changes.

D. Donning sterile gloves is not required for medication administration through a central line. Clean gloves are sufficient, while sterile technique is reserved for dressing changes and catheter insertions.

A. "The surgeon will make a small incision in your abdomen." B. "You may experience referred shoulder pain." C. "Your procedure will be scheduled during menstruation." D. "Warm saline will be instilled via the cervix."

Correct Answer is B

Explanation

A. "The surgeon will make a small incision in your abdomen.": A hysterosalpingography is a fluoroscopic imaging procedure that does not require surgical incisions. Contrast dye is injected through the cervix to visualize the uterus and fallopian tubes.

B. "You may experience referred shoulder pain.": Referred shoulder pain is a common side effect due to peritoneal irritation caused by the contrast dye if it spills into the peritoneal cavity, particularly when the fallopian tubes are patent. This discomfort is temporary and resolves on its own.

C. "Your procedure will be scheduled during menstruation.": The test is typically scheduled after menstruation but before ovulation (days 7-10 of the cycle) to ensure the uterus is clear of blood and to avoid disrupting an early pregnancy.

D. "Warm saline will be instilled via the cervix.": Hysterosalpingography uses iodine-based contrast dye for X-ray imaging, not warm saline. Saline infusion is used in sonohysterography, which is an ultrasound-based procedure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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