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 B
Explanation
A. Securing the drain to the client's bed sheet is not an appropriate method for securing the JP drain; it should be secured to the client’s gown or clothing to avoid tension on the drain.
B. Expelling the air from the JP bulb after emptying to re-establish suction is necessary to ensure that the drain continues to function correctly by maintaining negative pressure.
C. Measuring the drainage every hour for the first 8 hr postoperative is more frequent than necessary; monitoring can be done every 4-8 hours depending on the protocol.
D. Removing the JP drain when the drainage has ceased, covering the opening with sterile gauze is incorrect; the drain should be removed per the surgeon’s orders, and the site should be covered with a sterile dressing.
Correct Answer is A
Explanation
A. Nosebleeds (epistaxis) are a common adverse effect of bevacizumab, as it can cause bleeding due to its anti-angiogenic properties.
B. Temporary loss of smell is not a recognized adverse effect of bevacizumab.
C. Weight gain is not typically associated with bevacizumab treatment.
D. Mild hearing loss is not a common adverse effect of bevacizumab.
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