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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Jugular vein distention is more commonly associated with right ventricular heart failure, as it indicates increased central venous pressure.

Choice B reason: Bilateral basilar crackles are a hallmark sign of left ventricular heart failure. They occur due to pulmonary congestion and enema, resulting from the left ventricle's inability to effectively pump blood out to the body, causing fluid to back up into the lungs.

Choice C reason: 3+ pitting enema in the ankles is more characteristic of right ventricular heart failure, where fluid accumulates in the peripheral tissues.

Choice D reason: Hepatomegaly with right upper quadrant (RUQ) tenderness is also more indicative of right ventricular heart failure, as it reflects congestion in the liver due to increased venous pressure.

A. Apply soft restraints to all extremities. B. Remove objects that could cause injury. C. Place pillows around the client's head. D. Administer oxygen per nasal cannula.

Correct Answer is B

Explanation

Choice A reason: Applying soft restraints to all extremities is not appropriate during a seizure as it can increase the risk of injury. The priority is to ensure the client's safety by preventing injury without restraining them.

Choice B reason: Removing objects that could cause injury is crucial. During a seizure, the client may move unpredictably, and any nearby objects could pose a risk of harm. Clearing the area ensures the client has a safe space to have the seizure without additional hazards.

Choice C reason: Placing pillows around the client's head can provide some protection, but it is not as immediately effective or necessary as removing potentially harmful objects from the surrounding area. Ensuring a clear and safe environment is the primary concern.

Choice D reason: Administering oxygen per nasal cannula is not the first priority during a seizure. While maintaining oxygenation is important, the immediate focus should be on ensuring the client's physical safety by removing dangerous objects. Once the seizure subsides, appropriate respiratory support can be provided if needed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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