During a central IV line insertion at the bedside, a client reports shortness of breath and becomes tachypneic. Which finding should a nurse suspect indicates the client developed a pneumothorax?
Muffled heart sounds.
Sudden hemoptysis.
Absent breath sounds on the affected side.
Declining respiratory rate.
The Correct Answer is C
Choice A rationale
Muffled heart sounds are not a typical sign of pneumothorax. They are more commonly associated with conditions such as pericardial effusion or cardiac tamponade.
Choice B rationale
Sudden hemoptysis, or coughing up blood, is not a typical sign of pneumothorax. It is more commonly associated with conditions such as pulmonary embolism or lung cancer.
Choice C rationale
Absent breath sounds on the affected side is a typical sign of pneumothorax. When air enters the pleural space and causes the lung to collapse, breath sounds may be absent or significantly decreased on the affected side.
Choice D rationale
A declining respiratory rate is not a typical sign of pneumothorax. In fact, a rapid respiratory rate (tachypnea) is more commonly observed in pneumothorax due to the body’s attempt to compensate for the decreased lung capacity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While it’s important to reassure the patient, saying “It’s uncertain if your smoking led to the cancer” might be misleading. Smoking is a major risk factor for lung cancer, but it’s also true that not everyone who smokes gets lung cancer, and not everyone who gets lung cancer has smoked.
Choice B rationale
This response validates the patient’s feelings and opens up a dialogue about their specific fears. It allows the nurse to provide targeted education and reassurance.
Choice C rationale
Asking “Do you feel guilty because you used to smoke?” might make the patient feel more guilty or judged. It’s better to provide support and understanding.
Choice D rationale
While it’s true that fear is a normal reaction and that the healthcare team is there to support the patient, this response doesn’t address the patient’s specific concerns or feelings of guilt.
Correct Answer is C
Explanation
Choice A rationale
While it’s possible for a virus to reactivate in the body, this is not typically the case with the common cold. The common cold is a viral infection primarily in the nose, with most people recovering in seven to ten days.
Choice B rationale
While it’s true that cold season tends to end as the weather warms up, this doesn’t address the patient’s concern about their repeated colds. It’s important to note that colds are caused by viruses, which can be spread year-round, although they are more common in the colder months.
Choice C rationale
This is the correct answer. The common cold is indeed a virus that can be spread by a person two days before they experience any symptoms. This means that people can spread the virus before they know they’re sick, which can make it difficult to avoid catching a cold.
Choice D rationale
While wearing a mask can help prevent the spread of viruses, it’s not typically necessary for someone who is simply sensitive to colds. Masks are more commonly recommended for people who are already sick to prevent them from spreading the virus, or for people who are at high risk of serious complications from the cold.
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