Author Question: The nurse is assessing a client with a severe left pleural effusion. Which assessment data does the ... (Read 46 times)

RYAN BANYAN · **on:** Jun 25, 2018

The nurse is assessing a client with a severe left pleural effusion. Which assessment data does the nurse anticipate based on the client's diagnosis? Select all that apply.

1. Absent breath sounds on the left side.
2. Tracheal shift to the right.
3. Hyperresonance upon percussion.
4. Bronchial breath sounds of the right side.
5. Pleural friction rub auscultated.

Question 2

While palpating respiratory expansion on a client the nurse notes movement on only one side of the chest. Which conditions are associated with this assessment finding? Select all that apply.

1. Atelectasis.
2. Chronic bronchitis.
3. Lobar pneumonia.
4. Pleural effusion.
5. Congestive heart failure.

helenmarkerine · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 1, 2, 5
In this condition, fluid accumulates in the pleural space and may result in absent breath sounds on the affected side, a tracheal shift to the unaffected side, and a pleural friction rub. The trapping of air in the alveoli will produce a sound of hyperresonance upon percussion. This is not a typical finding in someone who has been diagnosed with a pleural effusion. Bronchial breath sounds of the right side are not a typical finding in someone who has been diagnosed with a pleural effusion.

Answer to Question 2

Correct Answer: 1, 3, 4
Atelectasis is a condition in which there is an obstruction of airflow. Lung tissue may collapse from airway obstruction, such as a mucous plug, lack of surfactant, or a compressed chest wall. Atelectasis will result in decreased lung expansion on the client's affected side. Lobar pneumonia is due to an infection that causes fluid, bacteria, and cellular debris to fill the alveoli. It may result in decreased lung expansion on the client's affected side. Pleural effusion refers to fluid accumulating in the pleural space. It may result in decreased lung expansion on the client's affected side. Chronic bronchitis results in chronic inflammation of the tracheobronchial tree, which leads to increased mucous production and blocked airways. It does not result in decreased lung expansion on one side. Congestive heart failure occurs when increased pressure in the pulmonary veins causes interstitial edema around the alveoli and may cause edema of the bronchial mucosa. It does not result in decreased lung expansion on one side.