A nurse is assessing a client following the insertion of a chest tube. Which of the following findings indicate to the nurse that the client is experiencing a tension pneumothorax?
Crackles on auscultation
Tracheal deviation
Hypertension
Hemoptysis
The Correct Answer is B
A. Crackles on auscultation: Crackles are indicative of fluid in the alveoli, commonly seen in conditions like pneumonia, pulmonary edema, or atelectasis. They are not a hallmark of tension pneumothorax, which primarily involves air accumulation in the pleural space causing lung collapse and mediastinal shift rather than alveolar fluid accumulation.
B. Tracheal deviation: Tracheal deviation away from the affected side is a classic sign of tension pneumothorax. As air accumulates under pressure in the pleural space, it shifts the mediastinum, compresses the opposite lung, and can impede venous return, leading to life-threatening respiratory and hemodynamic compromise. Immediate decompression is required.
C. Hypertension: Tension pneumothorax typically causes hypotension rather than hypertension. The increasing intrathoracic pressure impairs venous return to the heart, reducing cardiac output and leading to shock. Hypertension is not expected.
D. Hemoptysis: Hemoptysis, or coughing up blood, is associated with lung parenchymal injury, infections, or pulmonary embolism. It is not a primary feature of tension pneumothorax, which involves air accumulation and mediastinal shift rather than bleeding into the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "The condition may cause you to have frequent constipation.": Ulcerative colitis typically causes diarrhea rather than constipation due to inflammation and ulceration of the colon mucosa. Clients often experience frequent, loose, or bloody stools, sometimes with urgency, making constipation an inaccurate expectation.
B. "Your diet should be low in animal fat and sugar.": Diet modifications can help manage symptoms of ulcerative colitis. Diets low in animal fat and refined sugars have been associated with reduced inflammation and fewer flare-ups. High-fat and high-sugar foods can exacerbate diarrhea and abdominal discomfort, making this an important dietary recommendation.
C. "Choose nuts such as almonds for a snack.": Nuts are high in fiber and fat, which can be difficult to digest during active ulcerative colitis and may exacerbate diarrhea or cause intestinal irritation. Soft, low-residue foods are typically recommended during flares to reduce gastrointestinal workload.
D. "The condition is controlled by diet, not treated with medication.": While diet helps manage symptoms, ulcerative colitis is primarily treated with anti-inflammatory medications (e.g., aminosalicylates, corticosteroids) and immunomodulators. Diet alone is insufficient for controlling inflammation or inducing remission.
Correct Answer is A
Explanation
A. A client who has measles: Measles is a highly contagious viral infection transmitted via airborne droplets that can remain suspended in the air for long periods. Implementing airborne precautions, including placing the client in a negative-pressure room and using an N95 or higher-level respirator, is essential to prevent transmission to others.
B. A client who has vancomycin-resistant enterococcus: VRE is transmitted primarily via contact with contaminated surfaces or direct contact with infected persons. Contact precautions, including gloves and gowns, are appropriate, but airborne precautions are not necessary.
C. A client who has pertussis: Pertussis (whooping cough) is transmitted through respiratory droplets, so droplet precautions, including a surgical mask for staff and visitors, are indicated. Airborne precautions are not required.
D. A client who has respiratory syncytial virus: RSV is primarily spread via contact with respiratory secretions and droplets. Contact and droplet precautions are recommended, but airborne precautions are not needed unless an aerosol-generating procedure is being performed.
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