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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
Based on the information collected, the client is likely experiencing Hypoxia related to Tonic clonic seizure
Rationale
The severe drop in oxygen saturation and the observation of violent jerking movements are consistent with a tonic-clonic seizure, which can be precipitated or exacerbated by significant hypoxia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
