The nurse palpates the posterior chest while the patient says '99' and notes absent fremitus. Which action should the nurse take next?

Correct Answer: D

Rationale: The correct answer is D because auscultating breath sounds is the next appropriate action after noting absent fremitus. This helps assess for additional signs of respiratory issues. Palpating the anterior chest for barrel chest (choice A) is not necessary at this point. Encouraging the patient to turn, cough, and deep breathe (choice B) is more appropriate for assessing for chest expansion. Reviewing the chest x-ray report for evidence of pneumonia (choice C) is premature without further assessment of breath sounds.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulant medication. This is the priority intervention because anticoagulants help prevent the existing clot from getting larger and reduce the risk of new clots forming. Administering anticoagulant medication promptly is essential to prevent complications like worsening of the pulmonary embolism or development of new clots. B: Positioning the patient flat may worsen the condition by reducing blood flow to the lungs. C: Encouraging ambulation may dislodge the clot and lead to a life-threatening situation. D: Chest physiotherapy may not address the underlying cause of the pulmonary embolism and could potentially dislodge the clot. In summary, administering anticoagulant medication is the priority intervention as it directly addresses the pathophysiology of the condition and reduces the risk of complications.

Correct Answer: B

Rationale: Correct Answer: B - "I should sleep on my back for better airflow." Rationale: 1. Sleeping on the back can worsen obstructive sleep apnea by causing the tongue and soft tissues to block the airway. 2. The optimal sleeping position for CPAP therapy is usually on the side to maintain open airways. 3. Choices A, C, and D are correct as consistent CPAP usage, regular cleaning, and weight loss can improve sleep apnea symptoms.

Correct Answer: D

Rationale: The correct answer is D because assessing the patient's reported exertional dyspnea directly evaluates the symptom that the patient is experiencing. Improvement in exertional dyspnea indicates that the treatment is effective in managing the patient's condition. It is essential to focus on the patient's subjective experience to determine treatment effectiveness. Choices A, B, and C are incorrect because: A: Heart rate below 100 beats per minute may or may not be relevant to assessing exertional dyspnea improvement. It does not directly evaluate the patient's reported symptom. B: Improved lung fields on a chest x-ray may suggest some improvement but do not directly correlate with the patient's symptom of exertional dyspnea. C: Stable blood pressure is important but does not directly assess the patient's reported symptom of exertional dyspnea.

Correct Answer: B

Rationale: The correct answer is B: Paradoxical chest wall movement. This finding is most concerning because it indicates a flail chest, a serious condition where a segment of the chest wall moves in the opposite direction of the rest of the chest during breathing, leading to respiratory compromise and potential lung injury. This requires immediate medical intervention. A: Mild chest wall bruising is less concerning as it may be a common finding in chest trauma without indicating severe underlying issues. C: A respiratory rate of 20 breaths per minute falls within the normal range and may not necessarily indicate a critical condition. D: Subcutaneous emphysema near the injury site can be concerning but is typically not as immediately critical as paradoxical chest wall movement in terms of respiratory compromise.