A patient with pulmonary embolism is receiving anticoagulant therapy. Which lab result should the nurse monitor to evaluate treatment effectiveness?

Correct Answer: B

Rationale: The correct answer is B: Prothrombin time/international normalized ratio (PT/INR). PT/INR measures the clotting ability of the blood and is used to monitor the effectiveness of anticoagulant therapy. In patients with pulmonary embolism, the goal is to prevent further clot formation. Monitoring PT/INR helps adjust anticoagulant dosage to maintain therapeutic levels and prevent bleeding or clotting complications. Incorrect Choices: A: CBC provides information about red and white blood cells, not directly related to anticoagulant therapy monitoring. C: Serum creatinine is used to assess kidney function, not specifically related to anticoagulant therapy monitoring. D: Electrolyte levels are important for overall health, but not directly related to monitoring anticoagulant therapy effectiveness.

Correct Answer: C

Rationale: The correct action is to check the system for air leaks (Option C) because bubbling in the water-seal chamber indicates air is leaking into the system, which can compromise the chest tube's function. By identifying and addressing the air leak, the nurse can ensure proper drainage and prevent complications. Clamping the chest tube (Option A) can lead to tension pneumothorax. Increasing suction (Option B) can worsen the problem. Notifying the healthcare provider (Option D) should be done after checking for air leaks.

Correct Answer: A

Rationale: The correct answer is A: Use of accessory muscles during respiration. This finding in a patient with asthma indicates a need for immediate intervention because it signifies severe respiratory distress and impending respiratory failure. Accessory muscle use suggests that the patient is struggling to breathe and is unable to maintain adequate oxygenation. This requires prompt medical attention to prevent further deterioration. Summary: B: Oxygen saturation of 92% on room air may indicate mild hypoxemia but is not as urgent as the use of accessory muscles. C: Mild expiratory wheezing is a common finding in asthma exacerbations and may not necessarily require immediate intervention. D: Peak expiratory flow rate of 85% of personal best indicates moderate airflow limitation but does not necessarily require immediate intervention unless accompanied by other severe symptoms.

Correct Answer: C

Rationale: The correct answer is C: Oxygen saturation of 85% despite oxygen therapy. This finding indicates severe hypoxemia, which can lead to tissue damage or organ failure. Immediate notification is crucial to address the patient's inadequate oxygenation. Crackles in the lower lung fields (A) are common in pneumonia but don't require immediate notification. A respiratory rate of 24 breaths per minute (B) may indicate respiratory distress but is not as concerning as severe hypoxemia. Productive cough with yellow sputum (D) is a common symptom of pneumonia but doesn't indicate an urgent need for provider notification.

Correct Answer: B

Rationale: The correct answer is B: Check the chest tube for kinks or obstructions. The priority action is to ensure the chest tube is functioning properly as diminished breath sounds could indicate a blockage or dislodgement. By checking for kinks or obstructions first, the nurse can address the immediate issue and prevent complications. Reassessing after 30 minutes (A) delays necessary intervention. Clamping the tube (C) can lead to a tension pneumothorax. Notifying the healthcare provider (D) is important but not immediate in this situation.