The chest x-ray for a client who is admitted for pneumonia shows a pleural effusion with decreased air flow in the entire left upper lobe. After auscultating the left upper lobe, which breath sounds documented by the nurse verify the x-ray findings?
Crackles or coarse rales.
Pleural friction rub.
Low pitched, sonorous rhonchi.
Diminished breath sounds.
The Correct Answer is D
Choice A reason: Crackles or coarse rales are typically associated with fluid in the airways, such as in cases of congestive heart failure or pneumonia, but they do not directly indicate a pleural effusion.
Choice B reason: A pleural friction rub is associated with pleuritis, where the inflamed pleurae rub against each other. It does not indicate decreased air flow in a specific lobe.
Choice C reason: Low pitched, sonorous rhonchi are related to secretions in the larger airways and are not specific to a pleural effusion or decreased air flow in one lobe.
Choice D reason: Diminished breath sounds in the left upper lobe are consistent with a pleural effusion, as the fluid can reduce air flow and sound transmission in that area. This finding directly correlates with the x-ray results showing decreased air flow in the entire left upper lobe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Decreasing foods high in fat or trans fats is generally good for overall health, but it is not specifically related to managing diverticulosis. Focusing on fibber intake is more important for this condition.
Choice B reason: Eliminating caffeine and chocolate might be helpful for certain digestive issues, but it is not directly related to diverticulosis management. The primary concern for diverticulosis is to ensure adequate fibber intake to promote regular bowel movements and prevent complications.
Choice C reason: Augmenting the intake of dairy products is not directly beneficial for diverticulosis and could potentially cause discomfort in individuals who are lactose intolerant. It is not a recommended dietary modification for this condition.
Choice D reason: Increasing the intake of insoluble fibber is crucial for managing diverticulosis. Insoluble fibber helps to increase stool bulk and promote regular bowel movements, which can reduce the risk of diverticula formation and prevent flare-ups of diverticulitis. Foods rich in insoluble fibber include whole grains, vegetables, and fruits.
Correct Answer is B
Explanation
Choice A reason: Placing the client in a darkened room may help alleviate symptoms if the headache is related to migraine or sensitivity to light, but it does not address the potential underlying cause of the severe headache and blurred vision in a client with a history of diabetes and hypertension.
Choice B reason: Obtaining a blood pressure reading is the most critical first step. Severe headache and blurred vision can be symptoms of hypertensive crisis, which is a medical emergency that requires immediate attention to prevent complications such as stroke or organ damage. Checking the blood pressure will help determine if the client's symptoms are due to elevated blood pressure.
Choice C reason: Administering an oral analgesic may provide temporary relief for the headache, but it does not address the potential underlying causes of the symptoms. The priority is to assess and manage any potentially life-threatening conditions.
Choice D reason: Performing a finger stick glucose test is important for monitoring blood glucose levels in a client with diabetes. However, in the context of the severe headache and blurred vision, the immediate concern should be to rule out hypertensive crisis by checking the blood pressure first. Blood glucose can be checked after ensuring the client's blood pressure is not critically high.
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