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A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
- A. The client rates pain as a 5/10 at the site of the procedure.
- B. A small amount of drainage from the site is noted.
- C. Pulse oximetry is 93% on 2 L of oxygen.
- D. The trachea is shifted toward the opposite side of the neck.
Correct Answer: D
Rationale: The correct answer is D because the trachea shifted towards the opposite side indicates a potential pneumothorax, a serious complication following thoracentesis. Immediate action is needed to prevent respiratory distress. Choices A and B are common post-procedural findings and may not require immediate action. Choice C, while indicating hypoxemia, does not pose an immediate threat compared to a tracheal deviation.
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A male patient has a sucking stab wound to the chest. Which action should the nurse take first?
- A. Drawing blood for a hematocrit and hemoglobin level.
- B. Applying a dressing over the wound and taping it on three sides.
- C. Preparing a chest tube insertion tray.
- D. Preparing to start an I.V. line.
Correct Answer: B
Rationale: The correct answer is B. Applying a dressing over the wound and taping it on three sides should be done first to prevent air from entering the wound and causing a tension pneumothorax. This action helps stabilize the wound and minimizes the risk of further complications. Drawing blood for hematocrit and hemoglobin (A) is not the priority in this situation. Chest tube insertion (C) and starting an IV line (D) can be necessary interventions but are not the immediate priority in managing a sucking chest wound.
The nurse recognizes that additional teaching is needed when the patient with asthma says
- A. a. I should exercise every day if my symptoms are controlled.
- B. b. I may use over-the-counter bronchodilator drugs occasionally if I develop chest tightness.
- C. c. I should inform my spouse about my medications and how to get help if I have a severe asthma attack.
- D. A diary to record my medication use, symptoms, peak expiratory flow rates, and activity levels will help in adjusting my therapy.
Correct Answer: D
Rationale: Additional teaching is needed when the patient mentions using over-the-counter bronchodilator drugs occasionally. This is not recommended as it can mask underlying issues and delay proper treatment.
A client with suspected tuberculosis will most likely relate which clinical manifestations?
- A. Fatigue, weight loss, low grade fevers, night sweats.
- B. Dyspnea, chest pain, cough.
- C. Rapid shallow breathing, prolonged labored expiration, stridor.
- D. Dyspnea, hypoxemia, decreased pulmonary compliance.
Correct Answer: A
Rationale: The correct answer is A. A client with suspected tuberculosis is likely to experience fatigue, weight loss, low-grade fevers, and night sweats due to the chronic infection affecting the body. Fatigue and weight loss are common symptoms of active tuberculosis due to the systemic impact of the infection. Low-grade fevers and night sweats are characteristic of tuberculosis due to the body's immune response. These symptoms are key indicators of tuberculosis infection.
Choices B, C, and D are incorrect because they describe symptoms that are not typically associated with tuberculosis. Dyspnea, chest pain, and cough (Choice B) are more commonly seen in respiratory conditions such as pneumonia or bronchitis. Rapid shallow breathing, prolonged labored expiration, and stridor (Choice C) are indicative of airway obstruction rather than tuberculosis. Dyspnea, hypoxemia, and decreased pulmonary compliance (Choice D) are more characteristic of conditions such as chronic obstructive pulmonary disease (COPD) rather than tuberculosis.
Lungs are held tightly to the wall of the thorax due to
- A. the diaphragm and intercostal muscle contractions
- B. tight junctions between the lungs and the thorax
- C. surface tension of the pleural fluid and negative pressure in the cavity
- D. atmospheric pressure pushing on the lungs
Correct Answer: C
Rationale: The correct answer is C because the surface tension of the pleural fluid creates a cohesive force that keeps the lungs adhered to the thoracic wall. This, combined with the negative pressure in the pleural cavity, creates a vacuum effect that maintains the lungs' position.
A) The diaphragm and intercostal muscle contractions help with breathing but do not directly secure the lungs to the thorax.
B) Tight junctions between the lungs and thorax do not play a significant role in holding the lungs in place.
D) Atmospheric pressure does not hold the lungs against the thoracic wall; rather, it helps with breathing by aiding in lung expansion and contraction.
The nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which assessment finding indicates a potential complication and requires the nurse's immediate attention?
- A. Distended neck veins
- B. Left lower quadrant tenderness
- C. Urinary output of 40 mL/hr
- D. Excessive coughing
Correct Answer: A
Rationale: The correct answer is A: Distended neck veins. This finding indicates potential right-sided heart failure, a complication of COPD called cor pulmonale. The nurse should address this immediately to prevent further deterioration. Distended neck veins suggest increased central venous pressure and impaired right heart function. Left lower quadrant tenderness (B) is unrelated to COPD. Urinary output of 40 mL/hr (C) is within normal range. Excessive coughing (D) is a common symptom of COPD but does not indicate an immediate complication.