The client is admitted to the emergency department with chest trauma. What signs/symptoms indicate to the nurse the diagnosis of pneumothorax?
Barrel chest and polycythemia
Bronchovesicular lung sounds and bradypnea
Unequal lung expansion and dyspnea
Frothy bloody sputum and consolidation
The Correct Answer is C
A. Barrel chest and polycythemia: These findings are more characteristic of chronic obstructive pulmonary disease, especially emphysema. They reflect long-term adaptations to hypoxia and air trapping, not the acute onset seen in pneumothorax.
B. Bronchovesicular lung sounds and bradypnea: Bronchovesicular sounds are normal in some lung areas, and bradypnea is not a common feature of pneumothorax. Pneumothorax often presents with decreased or absent breath sounds on the affected side and increased respiratory rate due to hypoxia.
C. Unequal lung expansion and dyspnea: Unequal chest expansion occurs because the collapsed lung on the affected side does not inflate properly. Dyspnea results from impaired gas exchange, making this the most accurate sign combination of pneumothorax.
D. Frothy bloody sputum and consolidation: These findings suggest pulmonary edema or pneumonia rather than pneumothorax. Frothy sputum is often seen in left-sided heart failure, and lung consolidation is not a feature of air in the pleural space.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Status epilepticus:This refers to a prolonged or repeated seizure without recovery of consciousness between episodes. It is unrelated to respiratory conditions and does not apply to Lily’s worsening asthma symptoms.
B. Status asthmaticus:Status asthmaticus is a severe, prolonged asthma attack that does not respond to initial bronchodilator therapy. Lily’s persistent wheezing, increased work of breathing, and low oxygen saturation despite treatment indicate this potentially life-threatening condition that requires immediate medical intervention.
C. Postictal status:The postictal state follows a seizure and is characterized by confusion or fatigue. It has no relevance to Lily’s presentation, which involves respiratory, not neurological, distress.
D. Status post asthma:This phrase describes a condition following an asthma episode but does not reflect an ongoing or worsening attack. It is not a recognized clinical term for an acute, unresponsive asthma condition.
Correct Answer is C
Explanation
A. Nasal cannula:The nasal cannula provides low-flow oxygen with variable concentrations depending on the patient's respiratory rate and tidal volume. It does not deliver a precise or consistent oxygen concentration.
B. Simple face mask:The simple face mask delivers moderate concentrations of oxygen, generally between 40–60%, but it lacks a mechanism for precise control. Oxygen delivery fluctuates based on the patient’s breathing pattern and flow rate.
C. Venturi mask:The Venturi mask is designed to deliver a specific and consistent concentration of oxygen by using color-coded adaptors that mix oxygen with room air at fixed ratios. This makes it ideal for patients who require accurate oxygen titration, such as those with COPD.
D. Non-rebreather mask:A non-rebreather mask delivers high concentrations of oxygen (up to 90–100%) but does not allow for fine control of the exact oxygen percentage. It is used in emergencies when high oxygen delivery is needed, not for precise regulation.
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