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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Insulin aspart and NPH insulin: Insulin aspart is a rapid-acting insulin, and NPH is an intermediate-acting insulin. These can be mixed in the same syringe to provide both immediate and prolonged glucose control, with aspart covering postprandial spikes and NPH maintaining basal levels.
B. Insulin degludec and NPH insulin: Insulin degludec is an ultra-long-acting insulin and should not be mixed with any other insulin, as mixing can alter its absorption and effectiveness.
C. Insulin glargine and insulin detemir: Both glargine and detemir are long-acting insulins and should not be mixed with any other insulin, as this can interfere with their mechanism of providing a steady release.
D. Insulin lispro and regular insulin: Insulin lispro is a rapid-acting insulin, and regular insulin is short-acting. These insulins should not be mixed because they have different onset and peak times, which can lead to unpredictable glucose control.
Correct Answer is B
Explanation
A. "This device delivers heat via electrodes that are attached to the affected area.": A TENS unit does not use heat for pain relief. It works by delivering low-voltage electrical impulses to the skin, stimulating nerve fibers to reduce pain perception.
B. "Adjust the dial until you feel a pins-and-needles sensation.": The intensity of the electrical stimulation should be adjusted to a comfortable level where the client feels a tingling or pins-and-needles sensation. This indicates that the nerves are being stimulated appropriately for pain relief.
C. "You can apply the electrodes directly over sensitive areas of skin.": Electrodes should not be placed on irritated, broken, or sensitive skin, as this can cause discomfort or skin damage. Placement should follow guidelines to ensure effective and safe pain management.
D. "This device requires access to a 220-volt outlet.": TENS units are battery-operated and do not require a high-voltage power source. This makes them portable and convenient for home use.
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