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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Urine in the drainage appliance: The presence of urine in the drainage appliance is expected in a client with an ileal conduit, as this is the route for urine to exit the body.
b. Feces in the drainage appliance: An ileal conduit is created for urinary diversion, and feces
should not be present in the drainage appliance. This finding could indicate a complication and should be reported.
c. Mild edema of the stoma: Mild edema of the stoma may be expected in the early postoperative period and may not require immediate reporting unless it worsens.
d. Redness of the stoma: Some redness is normal around a stoma, and it may not require immediate reporting unless there are signs of infection or worsening inflammation.
Correct Answer is B
Explanation
a. “I will wait 10 min between each inhalation.”: There is no need to wait 10 minutes between
inhalations of albuterol. The usual recommendation is to wait 1-2 minutes if a second inhalation is needed.
b. “I will hold my breath at least 10 seconds after inhaling the medication.”: Holding the breath for at least 10 seconds after inhaling helps ensure that the medication reaches the lower airways and is absorbed effectively.
c. “I will tilt my head forward while inhaling the medication.”: Tilted head position is not necessary for using an inhaler; a proper inhalation technique is more critical.
d. “I will hold the inhaler with my non-dominant hand.”: The hand used to hold the inhaler is not as crucial as proper inhalation technique, but using the dominant hand may be more comfortable for most individuals.
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