A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of apneumothorax?

Inspiratory stridor

Expiratory wheeze

Coarse crackles

Absence of breath sounds.

Answer and Explanation

The Correct Answer is D

A. Inspiratory stridor - This is associated with upper airway obstruction and is not indicative of a pneumothorax.

B. Expiratory wheeze - Wheezing is commonly associated with lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD), not pneumothorax.

C. Coarse crackles - Coarse crackles are typically heard in conditions such as pneumonia or pulmonary edema, not pneumothorax.

D. Absence of breath sounds - This is a key manifestation of a pneumothorax. The air in the pleural space can prevent the lung from fully expanding, leading to the absence of breath sounds on the affected side.

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Correct Answer is A

Explanation

a. Postictal phase: The postictal phase refers to the period following a seizure during which the individual may be drowsy, confused, or sleepy. This phase can last varying amounts of time.

b. Presence of absence seizures: Absence seizures are characterized by brief episodes of staring and altered consciousness but do not typically have a postictal phase with prolonged sleepiness.

c. Aura phase: The aura phase occurs before a seizure and involves sensory or perceptual changes that serve as a warning sign. It does not describe the postictal state.

d. Presence of automatisms: Automatisms are repetitive, non-purposeful movements that can occur during certain types of seizures but do not describe the postictal state of sleepiness.

A. Determine the patency of the tubing. B. Notify the provider. C. Offer oral fluids. D. Administer a prescribed analgesic.

Correct Answer is A

Explanation

a. Determine the patency of the tubing: The first action should be to assess for any obstruction or kinks in the tubing. A blockage may be preventing the flow of urine.

b. Notify the provider: While notifying the provider may be necessary, assessing the tubing for patency is a more immediate action.

c. Offer oral fluids: While hydration is important, the priority is to ensure that the urinary catheter is functioning properly.

d. Administer a prescribed analgesic: Pain management is important postoperatively, but the

immediate concern is the lack of urinary output, which requires assessment and intervention to rule out catheter obstruction.

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A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of apneumothorax?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is A

Explanation

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