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 ["B","C","D","E","F"]
Explanation
Choice A Reason:
Easily getting back to sleep after awakening is incorrect. This is not typically a manifestation of obstructive sleep apnea. Instead, individuals with OSA often experience fragmented sleep due to frequent awakenings caused by apnea episodes.
Choice B Reason:
Many episodes of apnea per night is correct. Yes, individuals with obstructive sleep apnea experience many episodes of apnea (complete cessation of breathing) or hypopnea (partial obstruction of airflow) per night. These episodes can occur multiple times throughout the night, disrupting normal sleep patterns.
Choice C Reason:
Loud snort after breathing cessation is correct. This is a characteristic manifestation of obstructive sleep apnea. Individuals with OSA often make choking, snorting, or gasping sounds after a period of breathing cessation as they attempt to resume breathing.
Choice D Reason:
10 seconds or longer of breathing cessation is correct. Yes, breathing cessation episodes in obstructive sleep apnea typically last for 10 seconds or longer. These prolonged episodes of apnea contribute to oxygen desaturation and disrupted sleep.
Choice E Reason:
Daytime sleepiness is correct. Yes, daytime sleepiness is a common symptom of obstructive sleep apnea. Disrupted sleep patterns and frequent awakenings during the night can lead to excessive daytime sleepiness, fatigue, and decreased alertness.
Choice F Reason:
Frequent, loud snoring is correct. Yes, frequent, loud snoring is a hallmark symptom of obstructive sleep apnea. Snoring occurs due to the partial obstruction of airflow in the upper airway during sleep.
Correct Answer is B
Explanation
Choice A Reason:
Keeping lights turned to medium level in the evening is incorrect. This intervention is aimed at reducing environmental stimuli, which may be appropriate for some patients with neurological conditions to minimize sensory overload and promote rest. However, it is not a specific intervention for preventing cerebral aneurysm rupture.
Choice B Reason:
Maintaining the head of the bed between 30 and 45° is correct. Keeping the head of the bed elevated can help reduce intracranial pressure and decrease the risk of cerebral aneurysm rupture or rebleeding in patients with aneurysmal subarachnoid hemorrhage. This position promotes venous drainage from the brain and helps prevent increases in intracranial pressure.
Choice C Reason:
Administering hypotonic intravenous solutions is incorrect. Hypotonic intravenous solutions have a lower osmolarity than blood plasma and can lead to cerebral edema, which may exacerbate intracranial pressure and increase the risk of cerebral aneurysm rupture. Isotonic solutions, such as normal saline (0.9% NaCl) or lactated Ringer's solution, are typically preferred for fluid resuscitation and maintenance in patients at risk of cerebral aneurysm rupture.
Choice D Reason:
Reposition the client every shift is incorrect. Repositioning the client every shift helps prevent complications associated with immobility, such as pressure ulcers, pneumonia, and venous thromboembolism. While important for overall patient care, repositioning alone does not directly address the risk of cerebral aneurysm rupture.
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