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. Begin oxygen therapy: Oxygen therapy is the priority intervention for a client with a pulmonary embolism to improve oxygenation and prevent hypoxemia.

b. Start an IV infusion of lactated Ringer’s: While fluid resuscitation may be needed, oxygen therapy takes precedence to address the immediate respiratory compromise.

c. Initiate cardiac monitoring: Cardiac monitoring is important, but addressing oxygenation is the priority in a client with a pulmonary embolism.

d. Administer IV morphine: Pain management may be necessary, but the priority is to address the respiratory distress and potential hypoxemia associated with a pulmonary embolism.

A. Prothrombin time (PT) B. Platelet count C. White blood cell count (WBC) D. Activated partial thromboplastin time (aPTT)

Correct Answer is A

Explanation

a. Prothrombin time (PT): Warfarin affects the extrinsic pathway of the coagulation cascade, and PT is the primary diagnostic test used to monitor the therapeutic effect of warfarin. It measures

the time it takes for blood to clot.

b. Platelet count: Platelet count assesses the number of platelets in the blood and is not specifically used to monitor the effect of warfarin.

c. White blood cell count (WBC): WBC count assesses the number of white blood cells and is not specifically used to monitor the effect of warfarin.

d. Activated partial thromboplastin time (aPTT): While aPTT is a valuable test for monitoring the therapeutic effect of heparin, it is not the primary test for warfarin. Warfarin primarily affects the extrinsic pathway, and PT is more appropriate for monitoring its effects.

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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

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