A nurse is caring for a client who has a pneumothorax. The nurse is reviewing the client’s medical record.

What prescriptions should the nurse anticipate for a client who has a pneumothorax?

Choice A rationale
Reporting the absence of spontaneous respirations is important, but it is not the priority action. The patient is on mechanical ventilation, so the absence of spontaneous respirations is expected.
Choice B rationale
Encouraging the patient to attempt to breathe on their own is not the priority action. The patient is receiving mechanical ventilation, which means they are likely unable to breathe adequately on their own.
Choice C rationale
Providing passive range-of-motion exercises is important for overall patient mobility and prevention of complications such as deep vein thrombosis, but it is not the priority action in this case.
Choice D rationale
Responding to ventilator alarms is the priority action. Alarms may indicate a change in the patient’s condition or a problem with the ventilator. Immediate response is necessary to ensure the patient’s safety.

Choice A rationale
The initial assessment finding in a client diagnosed with a pulmonary embolism (PE) is typically dyspnea and anxiety. This is because a PE can block blood flow in the lungs, leading to difficulty breathing (dyspnea). The sudden onset of this symptom can cause significant anxiety in the patient.
Choice B rationale
An altered level of consciousness is not typically an initial finding in PE. While severe cases can lead to decreased oxygen levels in the blood, causing confusion or loss of consciousness, these are not usually initial symptoms.
Choice C rationale
Wheezing in lung bases is not a typical initial finding in PE. Wheezing is more commonly associated with conditions that cause narrowing of the airways, such as asthma or COPD12.
Choice D rationale
While an increased pulse and respiratory rate can occur in PE due to the body’s attempt to compensate for decreased oxygen in the blood, they are not the most specific initial findings. Dyspnea and anxiety are more characteristic initial symptoms of PE12.