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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Hospital-acquired pneumonia: Pneumonia that develops 48 hours or more after hospital admission is classified as hospital-acquired pneumonia (HAP). It is caused by pathogens acquired in the hospital setting, often involving multidrug-resistant organisms such as Pseudomonas aeruginosa, Staphylococcus aureus (including MRSA), and Klebsiella pneumoniae. Patients who are intubated, have prolonged hospital stays, or have weakened immune defenses are at higher risk.

B. Immunocompromised pneumonia: Pneumonia in immunocompromised patients occurs due to weakened host defenses, such as in individuals with HIV/AIDS, those undergoing chemotherapy, or transplant recipients on immunosuppressive therapy. While these patients can develop HAP, pneumonia due to opportunistic infections like Pneumocystis jirovecii or fungal infections is categorized separately.

C. Community-acquired pneumonia: Pneumonia acquired outside the hospital or within the first 48 hours of admission is classified as community-acquired pneumonia (CAP). Typical pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma pneumoniae. CAP is usually less resistant to antibiotics compared to HAP.

D. Viral pneumonia: Pneumonia caused by viral pathogens such as influenza, respiratory syncytial virus (RSV), or SARS-CoV-2 is classified based on the causative agent rather than the setting in which it was acquired. Although viruses can cause both CAP and HAP, the classification of pneumonia is determined by the timing of onset and exposure risks.

A. Veins that are most susceptible to a deep vein thrombosis are the peroneal, posterior tibial, popliteal and superficial femoral B. DVTS tend to mostly occur in the lower extremities but can occur in the upper extremities too C. A DVT is a type of venous thromboembolism (VTE), which is a blood clot that starts in the vein D. A deep vein thrombosis in the lower extremity has a low probability of becoming a pulmonary embolism

Correct Answer is D

Explanation

A. Veins that are most susceptible to a deep vein thrombosis are the peroneal, posterior tibial, popliteal and superficial femoral: This statement is correct. These veins are indeed among the most common sites for the development of DVT.

B. DVTs tend to mostly occur in the lower extremities but can occur in the upper extremities too: This statement is also correct. While DVTs primarily occur in the lower extremities, they can occur in the upper extremities as well, particularly in individuals with risk factors such as central venous catheters or certain medical conditions.

C. A DVT is a type of venous thromboembolism (VTE), which is a blood clot that starts in the vein: This statement is correct. DVTs are indeed classified as venous thromboembolism, which refers to blood clots that form in the venous system.

D. A deep vein thrombosis in the lower extremity has a low probability of becoming a pulmonary embolism: This statement is incorrect. A deep vein thrombosis in the lower extremity has a significant risk of becoming a pulmonary embolism if a thrombus dislodges and travels to the pulmonary circulation. It is essential to monitor and treat DVTs to reduce the risk of complications like pulmonary embolism.

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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.)

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Naxlex Comprehensive Predictor Exams

A pneumonia that occurs 48 hours or more after admission to the hospital is considered:

Correct Answer is A

Explanation

Which statement below is incorrect about a deep vein thrombosis (DVT)?

Correct Answer is D

Explanation

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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.)