A nurse is assessing a client who has a possible right pneumothorax.
Which of the following findings should the nurse expect?
Paradoxical chest movement.
Reduced right-sided breath sounds.
High-pitched stridor.
Intercostal retractions.
The Correct Answer is B
Choice A rationale:
Paradoxical chest movement refers to the abnormal inward movement of the chest during inhalation and outward movement during exhalation. It is not a typical finding in pneumothorax. Instead, paradoxical chest movement is often observed in conditions such as flail chest.
Choice B rationale:
Reduced right-sided breath sounds are a common finding in right pneumothorax. Air in the pleural space can cause lung collapse, leading to decreased or absent breath sounds on the affected side.
Choice C rationale:
High-pitched stridor is a sound heard during inspiration and indicates upper airway obstruction, often due to conditions like croup or epiglottitis. It is not a characteristic finding in pneumothorax.
Choice D rationale:
Intercostal retractions occur when the tissues between the ribs are pulled inward during inspiration. While retractions can be seen in various respiratory distress conditions, they are not specific to pneumothorax.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Maintaining eye contact with the newborn during feedings is a general caregiving practice and is not specific to managing neonatal abstinence syndrome. While eye contact and bonding are important for newborns, it does not address the symptoms of neonatal abstinence syndrome.
Choice B rationale:
Swaddling the newborn with his legs extended is not a specific action for managing neonatal abstinence syndrome. However, swaddling can provide comfort to some infants, but the positioning of the legs is not directly related to managing symptoms of withdrawal.
Choice C rationale:
Administering naloxone to the newborn is not a standard practice for managing neonatal abstinence syndrome. Naloxone is an opioid antagonist used to reverse opioid overdose in adults and is not typically used in newborns unless there are specific indications, which are rare.
Correct Answer is A
Explanation
Choice A rationale:
Preparing to assist with intubation is the appropriate action for a nurse caring for a child with suspected epiglottitis. Epiglottitis is a medical emergency where the airway can become severely compromised due to inflammation of the epiglottis. Intubation ensures a secure airway, allowing the child to breathe and preventing respiratory distress.
Choice B rationale:
Preparing a cool mist tent is not the priority in suspected epiglottitis. While humidified air can provide comfort for respiratory distress, it does not address the potential for airway obstruction. Intubation takes precedence in this critical situation.
Choice C rationale:
Suctioning the child's oropharynx may worsen the condition in suspected epiglottitis. Suctioning can stimulate the epiglottis, triggering a spasm and further obstructing the airway. Intubation is the primary intervention to secure the airway safely.
Choice D rationale:
Obtaining a throat culture is not the immediate action in suspected epiglottitis. While a throat culture may confirm the diagnosis, the priority is securing the airway to prevent respiratory distress and hypoxia.
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