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 A
Explanation
a. Ineffective airway clearance: This is the priority as it addresses the immediate threat to the client's respiratory status. Accumulation of thick, copious secretions can lead to airway
obstruction and respiratory distress.
b. Malnourishment: While important, addressing malnourishment is not an immediate
postoperative priority. The client may receive nutrition through alternative means until normal swallowing function is restored.
c. High risk for infection: Infection is a concern, but ensuring airway clearance takes precedence in the immediate postoperative period.
d. Impaired verbal communication: Verbal communication is important, but it is not as immediate a concern as ensuring the airway is clear to prevent respiratory compromise.
Correct Answer is C
Explanation
a. Slow: Atrial fibrillation is characterized by an irregular heart rate, but it may not necessarily be slow. The rate can vary, and it is irregularly irregular.
b. Not palpable: While atrial fibrillation can result in an irregularly irregular pulse, it is not necessarily indicative of a pulse that is not palpable.
c. Irregular: Atrial fibrillation is associated with an irregularly irregular pulse due to the chaotic and disorganized atrial activity.
d. Bounding: Bounding pulses are characterized by a forceful and strong pulse, which is not typically associated with atrial fibrillation.
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