A patient arrives in the ED after an automobile accident. Which of the following clinical manifestations leads the nurse to suspect a pneumothorax? (Select all that apply)
(Select All that Apply.)
Pulse oximetry 98%
Diminished breath sounds over painful chest area
Respiratory rate 34
ABG pH level of 7.38
Asymmetrical chest movements, especially on inspiration
Correct Answer : B,C,E
A. Pulse oximetry 98%: A pulse oximetry reading of 98% indicates adequate oxygen saturation, which does not strongly suggest a pneumothorax. Patients with a pneumothorax may have lower oxygen saturation levels, but this reading alone is not indicative of the condition.
B. Diminished breath sounds over painful chest area: Diminished breath sounds are a significant clinical manifestation of pneumothorax, as air in the pleural space prevents normal lung expansion and decreases airflow to the affected side.
C. Respiratory rate 34: An elevated respiratory rate (tachypnea) is often observed in patients with pneumothorax as they may struggle to breathe effectively. This clinical manifestation indicates respiratory distress and is consistent with the condition.
D. ABG pH level of 7.38: A pH level of 7.38 indicates acidosis, which may occur in cases of pneumothorax due to impaired gas exchange and respiratory distress. This abnormal finding on arterial blood gases supports the suspicion of pneumothorax.
E. Asymmetrical chest movements, especially on inspiration: Asymmetrical chest movements are a classic sign of pneumothorax, where the affected lung does not expand as fully as the unaffected lung during inspiration, leading to visible differences in chest wall movement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Controlling the blood pressure: Controlling blood pressure is crucial for reducing the risk of developing coronary artery disease (CAD). Even with a normal lipid panel, hypertension can significantly contribute to cardiovascular risk, and managing blood pressure helps protect against the development of CAD.
B. Moderate alcohol use: While moderate alcohol consumption may have some potential benefits for heart health, it is not a primary risk factor reduction strategy. The focus should be on more impactful lifestyle changes, particularly for individuals with normal lipid levels.
C. Eating a low-fat diet: Although a balanced diet is important for overall health, a low-fat diet specifically is not necessary for everyone, especially those with normal lipid levels. The emphasis should be on a heart-healthy diet that includes healthy fats, such as those from fish, nuts, and olive oil, rather than simply reducing fat intake.
D. Avoiding air pollution: Avoiding air pollution can have health benefits, but it is not a primary strategy for individuals seeking to reduce the risk of CAD. Addressing more direct risk factors, such as blood pressure management, is more critical in this context.
Correct Answer is A
Explanation
A. Carotid wall thinness: Carotid wall thinness is not considered a nontraditional risk factor for coronary artery disease (CAD). Traditional risk factors for CAD include age, gender, hypertension, hyperlipidemia, and smoking, while carotid wall thickness (rather than thinness) is often used as a marker for atherosclerosis and cardiovascular risk.
B. Chronic kidney disease: Chronic kidney disease (CKD) is recognized as a nontraditional risk factor for coronary artery disease. It is associated with increased cardiovascular risk due to factors like inflammation, mineral metabolism disorders, and increased vascular stiffness.
C. Coronary artery calcification: Coronary artery calcification is considered a nontraditional risk factor for CAD. It reflects the presence of atherosclerosis and is associated with an increased risk of cardiovascular events.
D. Markers of inflammation, ischemia, and thrombosis: Markers of inflammation (such as C-reactive protein), ischemia, and thrombosis (such as fibrinogen and D-dimer) are nontraditional risk factors for coronary artery disease. Elevated levels of these markers indicate increased cardiovascular risk and are used in risk stratification.
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