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 D

Explanation

A. Ensuring that the IV solution is infusing at the prescribed rate is an important task to maintain adequate fluid and electrolyte balance, especially if the client is experiencing signs of shock or low blood pressure. However, this action alone does not address the immediate need to assess or intervene for potential critical issues such as bleeding or severe hemodynamic instability.
B. Listening to lung sounds can help assess for pulmonary complications, such as fluid accumulation or atelectasis, which can be relevant postoperatively. However, in the context of hypotension, tachycardia, and altered mental status, the priority is to address potential critical issues related to circulatory stability and bleeding.
C. It is essential to inform the healthcare provider of the client's condition, but this should be done after initial interventions to stabilize the client. This action is necessary but not the first priority.
D. The first action should be to check for any signs of bleeding, especially after abdominal surgery where internal bleeding is a possibility.

Correct Answer is ["31"]

Explanation

Total volume in mL x Drop factor) / Total time in minutes.

For the vancomycin infusion, the total volume is 250 mL, the drop factor is 15 gtt/mL, and the total time is 120 minutes (2 hours).

The calculation is as follows: (250 mL x 15 gtt/mL) / 120 minutes = 31.25 gtt/min.

After rounding to the nearest whole number, the nurse should regulate the infusion to 31 gtt/min.

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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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Naxlex Comprehensive Predictor Exams

The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?

Correct Answer is D

Explanation

A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 ml to be infused over two hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the Infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["31"]

Explanation

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