Which of the following could the nurse expect to observe in an older adult client who has a pneumothorax?
Higher oxygen saturations of 98% to 99%
Lower oxygen saturations of 93% to 94%
Lower energy expenditure
Increased lung capacity
The Correct Answer is B
Choice A Reason:
Higher oxygen saturations of 98% to 99% is inappropriate. A pneumothorax involves the presence of air in the pleural space, which can compromise lung function and gas exchange. This compromised lung function typically leads to decreased oxygenation of the blood, resulting in lower oxygen saturations rather than higher saturations.
Choice B Reason:
Lower oxygen saturations of 93% to 94% is appropriate. A pneumothorax disrupts the normal exchange of oxygen and carbon dioxide in the lungs due to partial or complete lung collapse. As a result, the affected lung is unable to adequately oxygenate the blood, leading to lower oxygen saturations, which are indicative of hypoxemia.
Choice C Reason:
Lower energy expenditure is inappropriate. Energy expenditure is not typically affected by a pneumothorax. While the discomfort and respiratory distress associated with a pneumothorax may cause the individual to limit physical activity, there is no direct impact on overall energy expenditure.
Choice D Reason:
Increased lung capacity is inappropriate. A pneumothorax results in partial or complete collapse of the affected lung, reducing lung capacity rather than increasing it. The presence of air in the pleural space creates positive pressure, which can compress the lung and decrease its ability to expand fully during inhalation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Repeating the same question over and over is incorrect. Repeating the same question over and over is not a desired outcome of client education. It may indicate confusion or cognitive impairment rather than effective learning and understanding of COPD management.
Choice B Reason:
Awareness of COPD manifestations is incorrect. This is a desirable outcome of client education. Increasing the client's awareness of COPD manifestations, such as dyspnea, coughing, and sputum production, can help them recognize exacerbations early and take appropriate action to manage their condition.
Choice C Reason:
Anxiety and restlessness is incorrect. Anxiety and restlessness are not desired outcomes of client education. While anxiety is common in individuals with COPD due to the chronic nature of the condition and its impact on daily activities, education should aim to reduce anxiety by providing information and strategies for coping with COPD-related symptoms and challenges.
Choice D Reason:
Motivation and engagement of the client is correct. This is a desirable outcome of client education. Motivating and engaging the client in their own care empowers them to take an active role in managing their COPD and improving their quality of life. Education should provide information, support, and encouragement to help the client feel motivated and engaged in self-management strategies.
Correct Answer is C
Explanation
Choice A Reason:
Prothrombin time (PT) is a laboratory test that measures the time it takes for blood to clot is incorrect. While PT may be part of a comprehensive evaluation in some cases, it is not typically the initial diagnostic test performed for a TIA. A TIA is caused by a temporary disruption of blood flow to the brain, often due to an embolus or transient blockage in a cerebral artery, rather than a primary disorder of blood clotting.
Choice B Reason:
Complete blood count (CBC) is incorrect. A complete blood count (CBC) is a common laboratory test that evaluates the cellular components of the blood, including red blood cells, white blood cells, and platelets. While CBC can provide valuable information about hematological conditions such as anemia or thrombocytosis, it is not specific to diagnosing the cause of a TIA. TIA is primarily a vascular event related to transient ischemia in the brain rather than a disorder of blood cell counts.
Choice C Reason:
Computerized tomography angiography (CTA) is appropriate. CTA is a non-invasive imaging test that combines computed tomography (CT) scanning with contrast dye to visualize blood vessels throughout the body, including those in the brain. CTA can help identify any blockages, narrowing, or abnormalities in the blood vessels supplying the brain, which may be contributing to the TIA. It provides detailed images of the blood vessels' structure and can help guide further management and treatment decisions.
Choice D Reason:
Transesophageal echocardiogram (TEE) is inappropriate. Transesophageal echocardiogram (TEE) is an imaging test that provides detailed images of the heart and major blood vessels using sound waves. While TEE may be indicated in some cases of TIA to evaluate for potential cardiac sources of emboli (blood clots), such as atrial fibrillation or cardiac valve abnormalities, it is not typically the first-line diagnostic test performed in the emergency department setting for evaluating a TIA. Initial imaging studies such as CTA or magnetic resonance imaging (MRI) of the brain are usually prioritized to assess for acute changes in cerebral blood flow and potential causes of the TIA.
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