A nurse is gathering information on a patient who has pleural effusion.
What symptoms should the nurse anticipate?
Crackles heard over the patient’s lung fields.
Crepitus felt on the patient’s chest.
Substernal retractions observed on the patient’s chest.
Dullness heard when percussing the patient’s lung fields.
Correct Answer : A,D
Choice A rationale:
Crackles are a common symptom of pleural effusion. They are abnormal lung sounds that are heard when a patient with pleural effusion breathes in. The sound is caused by the opening of small airways and alveoli collapsed by fluid, exudate, or lack of aeration during expiration.
Choice B rationale:
Crepitus is not typically associated with pleural effusion. Crepitus is a crackling or grating sound or feeling produced by air in subcutaneous tissue or by the rubbing together of fragments of broken bone. In the context of respiratory health, crepitus might be felt if there is subcutaneous emphysema, where air gets into tissues under the skin covering the chest wall or neck.
Choice C rationale:
Substernal retractions are not a typical symptom of pleural effusion. Retractions are a sign of respiratory distress, but they are more commonly associated with conditions that cause upper airway obstruction or severe lung disease, such as asthma or pneumonia. Choice D rationale:
Dullness upon percussion is a classic sign of pleural effusion. When there is fluid in the pleural space, it prevents the normal resonant sound produced by the air-filled lungs from being heard. Instead, a dull sound is heard when the chest is percussed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Prone The prone position, in which a patient lies facedown, is beneficial for patients with pneumonia as it helps shift the fluid away from the back of the lungs, allowing more air to enter. It also improves ventilation in the lungs and reduces the risk of lung collapse. However, this position is not the most effective for maximum lung expansion in pneumonia patients.
Choice B rationale:
Side-lying Lateral positioning, in which the patient lies on one side, is recommended for patients suffering from pneumonia in just one lung. In this position, the pneumatic lung is exposed to a higher blood flow, resulting in greater oxygenation levels and improved lung expansion. This position can also help prevent lung injury by helping regulate pressure and improve aeration.
But again, this is not the most effective position for maximum lung expansion in pneumonia patients.
Choice C rationale:
Supine The supine position, where the patient lies flat on their back, is not the best position for a pneumonia patient. This position can cause the secretions to pool in the lungs, making it harder for the patient to breathe and potentially worsening their condition. Choice D rationale:
Upright Elevating the head of the bed is an effective way to improve lung expansion and oxygenation levels in pneumonia patients. This position also helps eliminate airway obstruction, reduces pressure on the lungs, and promotes drainage of fluids from the lungs. Therefore, the upright position is the most recommended for maximum lung expansion in pneumonia patients.
Correct Answer is A
Explanation
Choice A rationale:
Metabolic alkalosis can occur in clients who have excessive vomiting because of the loss of hydrochloric acid. When a person vomits, they lose hydrochloric acid, and the loss of this acid can cause the blood to become more basic. This shift in pH can lead to metabolic alkalosis, a condition characterized by high levels of bicarbonate in the blood, which makes it more alkaline (or less acidic). Symptoms of metabolic alkalosis can include muscle twitching, hand tremor, nausea or vomiting, and tingling in the face, hands or feet. In severe cases, it can cause prolonged muscle contractions or seizures.
Choice B rationale:
Respiratory acidosis is a condition that occurs when the lungs can’t remove enough carbon dioxide (CO2) from the body, which causes the body’s fluids, especially the blood, to become too acidic. This can occur due to conditions that affect the lungs such as chronic obstructive pulmonary disease (COPD), asthma, or sleep apnea. However, in the case of a patient experiencing nausea and vomiting, respiratory acidosis is less likely to be the primary concern.
Choice C rationale:
Metabolic acidosis occurs when the body produces too much acid, or when the kidneys aren’t removing enough acid from the body. This can be caused by conditions such as kidney disease, lactic acidosis, or ketoacidosis. In the case of a patient experiencing nausea and vomiting, the primary concern would not typically be metabolic acidosis, as vomiting leads to a loss of stomach acid, which would more likely result in a state of alkalosis, not acidosis.
Choice D rationale:
Respiratory alkalosis is a condition that occurs when you breathe too fast or too deep and carbon dioxide levels drop too low. This causes the pH of the blood to rise and become too alkaline. When the blood is too alkaline, it means that it is not carrying enough carbon dioxide. This condition can be caused by fever, hyperventilation, or lack of oxygen. In the case of a patient experiencing nausea and vomiting, respiratory alkalosis is not typically the primary concern.
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