Question:

The nurse is performing a respiratory assessment on a client who has a pleural effusion. The nurse should determine if the client has: 

1. Decreased chest movement on the affected side. 

2. Normal bronchial breath sounds. 

3. Hyperresonance on percussion. 

4. Fever.

A pleural effusion is a collection of fluid between the pleural layers of the lung. The effusion decreases chest wall movement on the affected side. The nurse should expect the breath sounds to be decreased or diminished over the affected area. Because of the presence of fluid, percussion would elicit dullness, not hyperresonance. Fever may be present if empyema (purulent pleural fluid with bacterial infection) has developed, but not in the case of a nonpurulent pleural effusion. 

CN: Basic care and comfort; CL: Analyze

Answer:1

翻译

问题：

护士正在对胸腔积液的病人进行呼吸评估。护士应确定病人是否：

1.患侧胸部活动减少。

2.支气管呼吸音正常。

3.超共振叩诊。

4.发烧。

答案：1

胸腔积液是肺胸膜层之间的积液。胸腔积液减少患侧胸壁运动。护士应该预料到呼吸音在受影响的区域减少或减弱。由于液体的存在，叩诊会引起浊音，而不是超共振。脓胸（化脓性胸腔积液伴细菌感染）可出现发热，但非化脓性胸腔积液则不存在发热。

CN：基本护理和舒适；CL：分析

小编寄语：Those who really have a skill, steadfastly working on a road, no matter where the tuyere, he will eventually become a continuous light.那些真正拥有一技之长、踏踏实实在一条路上努力的人，无论风口在哪里，他最终都会成为持续发光的人。