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A nurse is providing care for a client following a thoracentesis. If the client develops a pneumothorax, which of the following assessment findings should the nurse expect?

Pain on inhalation

Bradycardia

Friction rub

Stridor

Answer and Explanation

The Correct Answer is A

A. Pain on inhalation is a common symptom of pneumothorax due to pleural irritation and collapse of the lung.

B. Tachycardia, not bradycardia, is more likely in a client with a pneumothorax due to hypoxia.

C. A friction rub is associated with pleuritis, not pneumothorax.

D. Stridor is a sign of upper airway obstruction, not pneumothorax.

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Correct Answer is D

Explanation

A. A face shield is unnecessary unless there is a risk of splashing.

B. Masks are not needed for C. difficile, as it is not spread through airborne transmission.

C. Alcohol-based hand rubs are ineffective against C. difficile spores; handwashing with soap and water is required.

D. Contact precautions for C. difficile require the nurse to remove the protective gown and gloves inside the client's room to prevent contamination of outside areas.

A. Pick up the catheter 13 cm (5 in) from its tip. B. Perform the cleansing procedure with a fresh swab two times. C. Cleanse the tip of the penis in a side-to-side motion. D. Lift the penis so that it is perpendicular to the client's body.

Correct Answer is D

Explanation

A. The catheter should be picked up carefully, but the length from the tip is less important than maintaining sterility.

B. Cleansing the area is typically done with a single clean swab in a circular motion from the urethral meatus outward.

C. The correct technique for cleaning the penis is a circular motion from the urethra outward, not side-to-side.

D. Lifting the penis perpendicular to the body helps straighten the urethra, making catheter insertion easier and reducing the risk of injury.

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A nurse is providing care for a client following a thoracentesis. If the client develops a pneumothorax, which of the following assessment findings should the nurse expect?

Nursing Test Bank

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