A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse?

Reference Range:

Arterial Blood Gas (ABG) pH [7.35 to 7.45]

PaCO, [35 to 45 mm Hg]

HCO 21 to 28 mEq/L (21 to 28 mmol/L)]

PaO2 [80 to 100 mm Hg]

The client's chest x-ray Indicates decreased pleural effusion.

The client's arterial blood gas result is a pH 7.35, PaCO, 35 mm Hg, HCO,-26 mEq (26 mmol/L), PaO, 85 mm Hg.

The client has asymmetrical chest wall expansion.

The client reports pain at the insertion site.

Answer and Explanation

The Correct Answer is C

A.   A decreased pleural effusion on a chest x-ray is generally a positive outcome following a thoracentesis. It indicates that the procedure was successful in removing the excess fluid. This finding does not warrant immediate intervention and is expected after the procedure.
B.   The pH of 7.35 indicates acidosis (normal range is 7.35 to 7.45). The PaCO₂ is on the lower end of normal, suggesting that if there is an acid-base imbalance, it might be metabolic or mixed. The HCO₃⁻ is within normal limits, indicating no metabolic component. The PaO₂ is slightly below the normal range (80-100 mm Hg), which could be a concern but is not critically low.
C.   Asymmetrical chest wall expansion can indicate a complication such as pneumothorax (air in the pleural space), which could occur as a complication of thoracentesis. This finding warrants immediate intervention because it may signify a serious issue that requires prompt attention, such as the need for a chest tube or further evaluation.
D.   Pain at the insertion site is expected following a thoracentesis and is generally not an urgent concern unless it is severe or associated with other symptoms like fever, difficulty breathing, or signs of infection. This type of pain is usually managed with analgesics and does not typically require immediate intervention unless accompanied by more serious symptoms.

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Correct Answer is B

Explanation

A. While neutrophils are involved in the immune response and wound healing, they are more indicative of an acute infection. An increased wound size suggests a worsening chronic condition rather than an acute infection.
B. C-reactive protein (CRP) is a sensitive marker of inflammation. An increase in CRP often accompanies worsening inflammation, such as an increase in wound size. Evaluating CRP levels would provide valuable information about the overall inflammatory state of the client.
C. Platelets are involved in blood clotting and wound healing, but they are not directly related to the overall inflammatory process or wound size.
D. These electrolytes are important for overall health, but they are not directly related to wound healing or inflammation.

A. Encourage deep breathing and coughing exercises. B. Teach a family member to administer eye drops. C. Provide an eye shield to be worn while sleeping D. Obtain vital signs every 2 hours during hospitalization.

Correct Answer is C

Explanation

A. Deep breathing and coughing are important for general postoperative care but they are not specifically indicated for immediate postoperative cataract surgery. These exercises can increase intraocular pressure and potentially disrupt the healing process.
B. While it's important to educate caregivers about medication administration, this is not the priority in the immediate postoperative period. The patient should be stable and comfortable before teaching begins.
C. An eye shield is crucial to protect the operated eye from accidental injury during sleep. It prevents rubbing and potential complications.
D. Monitoring vital signs is essential for postoperative care. However, the frequency of every 2 hours is excessive for cataract surgery. Vital signs can be monitored less frequently, depending on the patient's condition.

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A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse? Reference Range: Arterial Blood Gas (ABG) pH [7.35 to 7.45] PaCO, [35 to 45 mm Hg] HCO 21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg]

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