A nurse is collecting data on a client who has a pleural effusion. Which of the following findings should the nurse expect?

Crackles auscultated over the client's lung fields

Crepitus palpated on the client's chest

Substernal retractions noted on the client's chest

Dullness percussed over the client's lung fields

Answer and Explanation

The Correct Answer is D

Choice A reason: Crackles auscultated over the client's lung fields are not a sign of pleural effusion. Crackles are abnormal breath sounds that indicate fluid or secretions in the alveoli. They can be heard in conditions such as pneumonia, heart failure, or pulmonary edema.

Choice B reason: Crepitus palpated on the client's chest is not a sign of pleural effusion. Crepitus is a crackling sensation that occurs when air leaks into the subcutaneous tissue. It can be felt in conditions such as pneumothorax, chest trauma, or chest surgery.

Choice C reason: Substernal retractions noted on the client's chest are not a sign of pleural effusion. Substernal retractions are inward movements of the chest wall below the sternum that indicate increased respiratory effort. They can be seen in conditions such as asthma, bronchiolitis, or croup.

Choice D reason: Dullness percussed over the client's lung fields is a sign of pleural effusion. Dullness is a flat sound that indicates the presence of a solid or liquid mass in the thoracic cavity. It can be detected in conditions such as pleural effusion, atelectasis, or consolidation.

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Correct Answer is A

Explanation

Choice A reason: Tachycardia is a sign of circulatory overload. Circulatory overload is a condition where the blood volume or rate of infusion is too high for the client's cardiovascular system. This causes the heart to beat faster and harder to pump the excess fluid, resulting in a high heart rate, or tachycardia.

Choice B reason: Weight loss is not a sign of circulatory overload. Weight loss is a condition where the body loses more calories than it consumes, resulting in a decrease in body mass. Weight loss can be caused by various factors, such as diet, exercise, illness, or medication. Weight gain, not weight loss, is a sign of circulatory overload, as the excess fluid accumulates in the body.

Choice C reason: Hypotension is not a sign of circulatory overload. Hypotension is a condition where the blood pressure is too low, which can impair the blood flow to the vital organs. Hypotension can be caused by various factors, such as dehydration, bleeding, shock, or medication. Hypertension, not hypotension, is a sign of circulatory overload, as the excess fluid increases the pressure in the blood vessels.

Choice D reason: Diaphoresis is not a sign of circulatory overload. Diaphoresis is a condition where the body sweats excessively, which can help to regulate the body temperature and eliminate toxins. Diaphoresis can be caused by various factors, such as fever, anxiety, exercise, or medication. Edema, not diaphoresis, is a sign of circulatory overload, as the excess fluid leaks into the interstitial spaces and causes swelling.

A. The pulse oximeter might not be accurate during times of excessive movement. B. We will notify the doctor if the pulse oximeter consistently reads 100%. C. The probe of the pulse oximeter can be applied to a finger or a toe. D. We will rotate the probe of the pulse oximeter every 24 hours.

Correct Answer is B

Explanation

Choice A reason: The pulse oximeter might not be accurate during times of excessive movement is a correct statement, as movement can interfere with the detection of the pulse and the oxygen saturation. The parents should try to keep the infant still and calm while using the pulse oximeter.

Choice B reason: We will notify the doctor if the pulse oximeter consistently reads 100% is an incorrect statement, as it indicates a misunderstanding of the normal range of oxygen saturation. The parents should not be alarmed if the pulse oximeter reads 100%, as it means that the infant's blood is fully saturated with oxygen. The normal range of oxygen saturation for infants is 95% to 100%.

Choice C reason: The probe of the pulse oximeter can be applied to a finger or a toe is a correct statement, as these are suitable sites for measuring the oxygen saturation in infants. The parents should make sure that the probe fits snugly and securely on the infant's finger or toe.

Choice D reason: We will rotate the probe of the pulse oximeter every 24 hours is a correct statement, as it helps to prevent skin irritation, pressure ulcers, or infection from prolonged contact with the probe. The parents should also check the infant's skin regularly for any signs of redness, swelling, or pain.

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A nurse is collecting data on a client who has a pleural effusion. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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