A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath.
The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)
Decreased lung sounds
Heart rate 110/min and regular
Oxygen saturation of 95%
Subcutaneous emphysema
Trachea midline
Puncture site dry
Correct Answer : A,B,D
Decreased Lung Sounds: Could indicate complications such as pneumothorax.
Heart Rate 110/min: Tachycardia may suggest a reaction to recent procedures or other underlying issues.
Subcutaneous Emphysema: Indicates possible air leakage that needs to be addressed.
Does Not Require Immediate Follow-Up:
Oxygen Saturation of 95%: Indicates acceptable oxygenation status.
Trachea Midline: Shows that there is no mediastinal shift.
Puncture Site Dry: Indicates that there is no ongoing issue at the insertion site
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Measuring the circumference of the thigh can help assess for swelling but is not specific for neurovascular assessment.
B. Palpating the femoral pulse is not as relevant for assessing neurovascular status at the site of a femur fracture; instead, the focus is on more distal pulses and sensations.
C. Instructing the client to wiggle his toes assesses motor function and circulation to the distal extremities, which are crucial for neurovascular status.
D. Monitoring the calf for edema is not the primary method for assessing neurovascular status at the site of a femur fracture; it’s more relevant for assessing for deep vein thrombosis.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"D"},"E":{"answers":"D"},"F":{"answers":"A"}}
Explanation
"I will have to stop watching television while I eat." Understanding: Multitasking while eating can increase the risk of choking, so focusing on the meal is important.
"I won't be able to eat nuts anymore." Understanding: Nuts are not appropriate for a Level 3 dysphagia diet due to their texture, which can be a choking hazard.
"My food will have to be the consistency of pudding." Understanding: A Level 3 dysphagia diet involves foods with a pudding-like consistency to minimize choking risk.
"I can have cream soups on this diet." No Understanding: Cream soups are typically too thin for a Level 3 dysphagia diet, which requires thicker consistencies.
"I will look up at the ceiling when I swallow." No Understanding: The correct practice is to keep the head level or slightly tilted forward, not to look up at the ceiling.
"I shouldn't drink liquids while I have food in my mouth." Understanding: Drinking liquids while chewing food can increase the risk of aspiration or choking.
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