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 ["100"]
Explanation
- Total volume to infuse: 200 mL
- Time for infusion: 2 hours
- The IV pump rate is calculated as: (Total Volume / Time) = Rate
- So, the calculation would be: (200 mL / 2 hr) = 100 mL/hr
- The nurse should set the IV pump to deliver 100 mL/hr.
Answer= 100
Correct Answer is D
Explanation
A. "I will not be allowed to drink much liquid for 12 hours after the procedure." is incorrect. The client is usually encouraged to drink fluids after the procedure to help flush the contrast material from the body.
B. "I can expect to have some itching during the procedure." is incorrect. Itching is not a typical expectation of the myelogram procedure.
C. "I will have a radioactive substance injected during the procedure." is incorrect. A myelogram involves the injection of a contrast dye, not a radioactive substance.
D. "I will need to keep my head elevated after the procedure." is correct. Keeping the head elevated after a myelogram helps prevent headaches and other complications from the procedure.
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