A nurse is caring for a client who reports shortness of breath and a dry non-productive cough.
The nurse notices that the client has decreased movement of the chest wall and absent breath sounds on the right side.
The nurse should suspect which of the following conditions?
Pulmonary infection.
Pleural effusion.
Pulmonary embolism.
Empyema.
The Correct Answer is B
Choice A rationale
A pulmonary infection, such as pneumonia, typically presents with productive coughing, fever, and crackles or wheezing upon auscultation rather than absent breath sounds. While chest movement might be slightly diminished due to pain, the hallmark signs of infection involve inflammatory markers and sputum production. The clinical picture of a dry cough combined with completely absent breath sounds and decreased chest wall movement on one side points more toward a mechanical obstruction or space-occupying fluid.
Choice B rationale
Pleural effusion is the accumulation of fluid in the pleural space between the lungs and the chest wall. This fluid acts as a barrier, preventing the lung from expanding fully and blocking the transmission of breath sounds to the stethoscope. Consequently, the nurse would observe decreased chest wall movement on the affected side and hear no air entry. The dry, non-productive cough is a common result of the fluid irritating the pleural linings without involving the bronchi.
Choice C rationale
A pulmonary embolism usually presents with sudden onset chest pain, significant tachypnea, and tachycardia. While shortness of breath is a primary symptom, breath sounds are often initially normal unless a large area of lung tissue has infarcted. It does not typically cause a localized absence of breath sounds or a visible decrease in chest wall movement unless it leads to secondary complications. The physical findings described are more indicative of fluid accumulation or a collapsed lung.
Choice D rationale
Empyema is the presence of infected, purulent fluid in the pleural space. While it shares some physical signs with a simple pleural effusion, such as absent breath sounds and decreased chest wall movement, it is almost always accompanied by systemic signs of severe infection, including high fever, chills, and pleuritic chest pain. Given the report only mentions a dry cough and shortness of breath without infectious markers, a general pleural effusion is a more likely initial clinical suspicion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A respiratory rate of 18 breaths per minute is well within the normal adult range of 12 to 20 breaths per minute. While a slight increase from 16 to 18 might be noted during a physical assessment, it does not provide physiological evidence of airway obstruction or secretion accumulation. Suctioning is an invasive procedure that can cause trauma, hypoxia, and bradycardia, and should only be performed based on specific clinical indications rather than minor fluctuations in a stable respiratory rate.
Choice B rationale
Suctioning should never be performed on a fixed schedule or a routine basis, such as every two hours. Performing tracheal suctioning without a clear clinical indication increases the risk of complications, including tracheal mucosal damage, nosocomial infections, and significant oxygen desaturation. Nursing standards of care dictate that the procedure must be based on a thorough physical assessment of the patient’s airway patency and breath sounds to ensure that the benefits of clearing secretions outweigh the risks.
Choice C rationale
The presence of congested or adventitious breath sounds, such as rhonchi or coarse crackles, during auscultation indicates that secretions are present in the large airways. These secretions can increase airway resistance, interfere with gas exchange, and increase the work of breathing. Auscultating bilateral lung fields and identifying these sounds provides a clear, objective clinical indication that tracheal suctioning is necessary to clear the airway and maintain adequate ventilation and oxygenation for the patient.
Choice D rationale
A pulse oximetry level of 95 percent is generally considered within the acceptable range for most clinical populations, as the standard normal range is 95 percent to 100 percent. While a drop in oxygen saturation can be a late sign of airway obstruction, a reading of 95 percent does not independently justify the need for tracheal suctioning. The nurse must prioritize assessment findings like visible secretions or audible congestion before oxygen levels fall into a hypoxic range.
Correct Answer is A
Explanation
Choice A rationale
Active laryngeal tuberculosis is highly contagious and is spread through small airborne droplets when the patient coughs, speaks, or sneezes. Because these particles can remain suspended in the air for long periods, the patient must be placed in an Airborne Infection Isolation Room. These rooms have a special ventilation system that maintains negative pressure, ensuring that air flows into the room from the hallway and is exhausted directly to the outside through a high-efficiency particulate air filter.
Choice B rationale
While gowns may be used during specific procedures where splashing is expected, the primary mode of transmission for tuberculosis is airborne, not contact. The most critical piece of personal protective equipment for staff is a fit-tested N95 respirator or a higher-level respirator, which filters out the tiny tubercle bacilli. Relying on gowns for staff and visitors without emphasizing respiratory protection would be an insufficient and unsafe practice for managing a patient with active, infectious laryngeal tuberculosis.
Choice C rationale
Removing personal protective equipment inside the hallway is incorrect for airborne precautions. The nurse should remove most PPE inside the room or in an anteroom to prevent the spread of contaminants. However, the N95 respirator must remain on until the nurse has completely exited the room and closed the door. Removing the respirator while still in the presence of potentially contaminated air, or handling PPE inappropriately in the public hallway, increases the risk of environmental contamination and exposure.
Choice D rationale
A semi-private room is entirely inappropriate for a patient with suspected active tuberculosis. Tuberculosis requires airborne precautions, not just droplet precautions. Droplet precautions are for larger particles that do not remain suspended in the air and only travel short distances. Airborne pathogens like Mycobacterium tuberculosis can travel much further and require negative pressure and specialized filtration. Placing such a patient in a semi-private room would expose other patients and staff to a high risk of infection. .
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