img-download-app
img-download-app

A nurse is caring for a client who underwent thoracic surgery. Which of the following should the nurse assess for manifestations of tension pneumothorax? 

Explanation

•Tension pneumothorax usually results from trauma (such as a stab wound) and develops when air is trapped in the pleural space during inspiration and cannot escape during expiration. The intrapleural pressure becomes greater than the lung tissue pressure, resulting in compression of the lung and surrounding structures.

•The clinical manifestations include Point of Maximal Impulse (PMI) shift; tracheal deviation toward the unaffected side; progressive cyanosis, restlessness, anxiety, and dyspnea; sudden sharp pain on the affected side with chest movement, breathing, or coughing; asymmetrical chest expansion; and diminished or absent breath sounds on the affected side.

•Evidence of labored breathing and hemodynamic compromise (for example, tachycardia, hypotension) suggest a possible tension pneumothorax.

•Crackles are a manifestation of acute pulmonary edema, seen with circulatory overload, resulting from delayed re-expansion of the affected lung after surgical treatment.

Visit our website for other NCLEX topics now!
Related questions

A patient with acne vulgaris asks the nurse what additional steps she can take to reduce the number and severity of lesions. The nurse should mention which of the following interventions?

A patient with cholecystitis is receiving nutritional counseling. The nurse should instruct the patient to:

A patient is admitted to the hospital for an acute exacerbation of heart failure. The nurse questions the patient about past and recent medical history. Which of the following would not contribute to this patient's exacerbation?

A patient is brought to the emergency department with complaints of chest pain radiating to the shoulder and shortness of breath. Which of the following lab tests is most important to obtain and evaluate?

A patient with a nasogastric tube (NG) is complaining of abdominal pain and feeling full. The patient underwent a colon resection 2 days ago and states that the discomfort has been progressing. What should the nurse do first?

The nurse is preparing to ambulate a patient to a chair after a total knee replacement. In order to protect the knee, the nurse should:

A home health nurse is examining a patient with a hiatal hernia. Which of the following would the nurse note as a classic sign of hiatal hernias?

A patient with hyperparathyroidism is prescribed estrogen and progesterone after refusing surgery. Which of the following should the nurse include in the patient's discharge instructions?

The nurse is caring for a patient with diabetic ketoacidosis. As part of the treatment plan, which action should the nurse take first?

A patient is admitted to the hospital with a myocardial infarction (MI). When assessing the patient for pain, the nurse is most likely to observe referred pain in what location?

The nurse is caring for a patient with urolithiasis. The patient needs to be evaluated to determine the type of stone before treatment can begin. The nurse would use which of the following to assist this process?

The nurse is assessing a patient who fell from a ladder. To help assess for the presence of a fracture, the nurse asks the patient if the pain:

The nurse is evaluating a patient with decreased cardiac output related to a myocardial infarction. Which of the following indicates improved cardiac output?

A 52-year-old male with Addison's disease is receiving discharge instructions related to disease management. During periods of stress, the patient should be instructed to

The nurse is assessing a patient with hyperthyroidism. Which of the following are signs and symptoms of hyperthyroidism?

The nurse is providing discharge instructions to a patient recently diagnosed with sarcoidosis. The nurse explains that the cause of sarcoidosis is

A nurse is assessing a patient for hemorrhage after the patient underwent a transsphenoidal hypophysectomy. Which of the following signs may be present?

A patient diagnosed with gastric cancer develops a stage two skin reaction from radiation therapy. The nurse is evaluating his symptoms and expects to find which of the following?

The nurse is assessing a patient with Hodgkin's lymphoma. Which one of the following is a feature of Hodgkin's lymphoma?

The nurse is assessing a 66-year-old patient with osteoarthritis. The patient also has a history of emphysema and Raynaud's phenomenon. The nurse would expect to observe which of the following symptoms?

The nurse is assigned to a patient suffering from mesothelioma. Which of the following is false in regards to mesothelioma?

A patient is being treated with radiation therapy after being diagnosed with Hodgkin's disease, Stage 1A. The nursing care plan for this patient should include which of the following?

The nurse is caring for a patient diagnosed with gastric cancer. The patient’s spouse asks about dietary changes as a way to reduce the risk of gastric cancer. Which of the following indicates that the spouse understands the nurse's instruction?

The nurse monitors the hypothalamic function of a patient with a head injury. Which assessment parameters should the nurse include in monitoring?

The nurse is providing education to a patient who underwent a left mastectomy with axillary lymph node dissection. The patient understood the postoperative restrictions and care if the patient agrees to

A nurse performing a neurological check on a patient who is one day post-craniotomy notices that the patient's right eye does not turn laterally. Which of the following cranial nerves should the nurse suspect is damaged?

The nurse is educating a patient with cervical cancer about the reasons for undergoing laser therapy. Which of the following statements indicate that the patient correctly understands the nurse's explanation?

The nurse is reviewing the x-ray of a patient with a fractured femur. The x-ray shows a fracture through the shaft with multiple bone fragments. What type of fracture is this?

The nurse is caring for a patient suspected of having cancer of the large intestine. The nurse understands that adenocarcinomas of the large intestine are most common in

A patient has presented to the ER and reports being thrown from a four-wheel ATV. The patient is awake, alert, and oriented, and is moving all extremities. The patient complains of a headache and neck pain rated as an 8 on a scale of 0 to 10. The nurse knows the first intervention for this patient should be which of the following?

The nurse is conducting a health education group for retired clients with chronic obstructive pulmonary disease (COPD) to help them improve their respiratory effort and gas exchange.  The nurse should place the most emphasis on which of the following?

The nurse is caring for a patient who is diagnosed with AIDS and was prescribed nevirapine (an NNRTI) two weeks ago. While assessing the patient, the nurse should be alert for

An educational session is being held in a local community about the risk factors of cervical cancer. The community health nurse knows that there is a need for further teaching when a woman identifies which of the following as a risk factor?

A patient is scheduled to undergo an intravenous pyelography. After conducting patient teaching for the procedure, the nurse knows that the patient needs further education when he states which of the following?