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A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath.

Exhibits

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

Answer and Explanation

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

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Correct Answer is D

Explanation

A. Advise the client to place one nitroglycerin tablet under his tongue as a precaution: Nitroglycerin is contraindicated in combination with phosphodiesterase type 5 inhibitors like tadalafil due to the risk of severe hypotension. This action could worsen the client's condition.
B. Tell the client to have someone bring him to an emergency department immediately: Skin flushing is a common side effect of tadalafil and not necessarily indicative of a medical emergency, especially in the absence of chest pain or other concerning symptoms.
C. Instruct the client to increase his intake of oral fluids until the skin flushing is relieved Increasing fluid intake is not likely to alleviate the skin flushing associated with tadalafil. This response does not address the client's concern adequately.
D. Reassure the client that skin flushing is a common side effect of the medication: Tadalafil, a phosphodiesterase type 5 inhibitor, commonly causes facial flushing as a side effect. Reassuring the client about this known side effect is appropriate, especially since he is not experiencing chest pain or other concerning symptoms.

A. The client cannot travel by air due to security screening. B. The client should hold his cell phone on the side opposite the ICD. C. The client can carry his ICD in a small pocket. D. The client should avoid the use of small electric devices.

Correct Answer is B

Explanation

A. The client cannot travel by air due to security screening is incorrect; clients with ICDs can travel by air but should inform security personnel about the ICD.

B. The client should hold his cell phone on the side opposite the ICD to avoid interference with the ICD’s functioning.

C. The client can carry his ICD in a small pocket is incorrect; the ICD is implanted and does not need to be carried.

D. The client should avoid the use of small electric devices is not entirely accurate; the client should follow specific guidelines but not avoid all small devices.

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A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath. Exhibits The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath.

Exhibits

The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)