Page 1609 - Saunders Comprehensive Review For NCLEX-RN

all that apply.

1. Dyspnea
2. Headache

3. Night sweats

4. A bloody, productive cough

5. A cough with the expectoration of mucoid sputum

582. The nurse performs an admission assessment on a client with a diagnosis of
tuberculosis. The nurse should check the results of which diagnostic test that
will confirm this diagnosis?
1. Chest x-ray
2. Bronchoscopy
3. Sputum culture
4. Tuberculin skin test

Answers

566. Answer: 2

Rationale: This client has sustained a blunt or closed-chest injury. Basic symptoms
of a closed pneumothorax are shortness of breath and chest pain. A larger
pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and
subcutaneous emphysema. Hyper-resonance also may occur on the affected side. A
sucking sound at the site of injury would be noted with an open chest injury.
Test-Taking Strategy: Focus on the subject, a blunt chest injury. Noting the word
blunt will assist in eliminating option 4, which describes a sucking chest wound
injury. Knowing that in a respiratory injury increased respirations will occur will
assist you in eliminating option 1. Option 3 can be eliminated because a barrel chest
is a characteristic finding in a client with chronic obstructive pulmonary disease.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Respiratory
Health Problem: Adult Health: Respiratory: Chest Injuries
Priority Concepts: Gas Exchange; Perfusion
Reference: Lewis et al. (2017), pp. 519-520.

567. Answer: 2, 3

Rationale: Clinical manifestations of chronic obstructive pulmonary disease
(COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen
desaturation with exercise, and the use of accessory muscles of respiration. Chest x-
rays reveal a hyperinflated chest and a flattened diaphragm if the disease is
advanced. Pulmonary function tests will demonstrate decreased vital capacity.

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