A nurse is caring for a 75-year-old male patient 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)
Diminished lung sounds
Heart rate 110/min and regular
Oxygen saturation of 95%
Subcutaneous emphysema
Trachea midline
Puncture site dry
Correct Answer : A,B,D
Choice A: Diminished Lung Sounds
Reason: Diminished lung sounds can indicate several serious conditions that require immediate follow-up. In the context of a patient who has just undergone a thoracentesis, diminished lung sounds could suggest a pneumothorax (collapsed lung), which is a known complication of the procedure. Pneumothorax occurs when air leaks into the space between the lung and chest wall, causing the lung to collapse. This condition can lead to severe respiratory distress and requires prompt intervention, such as the insertion of a chest tube to re-expand the lung. Additionally, diminished lung sounds could indicate reaccumulation of pleural fluid, which would necessitate further drainage or other interventions.
Choice B: Heart Rate 110/min and Regular
Reason: A heart rate of 110 beats per minute (bpm) is considered tachycardia, which is above the normal resting heart rate range of 60-100 bpm for adults. In elderly patients, a heart rate above 100 bpm can be particularly concerning as it may indicate underlying issues such as hypoxemia (low blood oxygen levels), infection, or cardiac problems. Tachycardia following a thoracentesis could be a sign of respiratory distress or pain, both of which require immediate assessment and management. It is crucial to determine the underlying cause of the elevated heart rate to prevent further complications.
Choice C: Oxygen Saturation of 95%
Reason: An oxygen saturation level of 95% is generally considered within the normal range (95-100%) for healthy individuals. However, in the context of a patient with a history of lung cancer, pleural effusions, and recent thoracentesis, this value might be borderline. While it does not require immediate follow-up, it should be monitored closely. Any further drop in oxygen saturation would necessitate intervention, such as supplemental oxygen or further diagnostic testing to determine the cause of the hypoxemia.
Choice D: Subcutaneous Emphysema
Reason: Subcutaneous emphysema is the presence of air in the subcutaneous tissue, which can occur as a complication of thoracentesis. It is often identified by a characteristic crackling sensation felt under the skin. This condition can indicate a more serious underlying issue, such as a pneumothorax or tracheal injury, both of which require immediate medical attention. Management of subcutaneous emphysema involves addressing the underlying cause, which may include the insertion of a chest tube or other interventions to remove the trapped air and prevent further complications.
Choice E: Trachea Midline
Reason: The trachea being midline is a normal finding and does not require immediate follow-up. A deviation of the trachea to one side can indicate a tension pneumothorax or significant pleural effusion, both of which are medical emergencies. However, in this case, the trachea is midline, suggesting that there is no immediate concern related to tracheal deviation.
Choice F: Puncture Site Dry
Reason: A dry puncture site is a normal finding post-thoracentesis and does not require immediate follow-up. It indicates that there is no active bleeding or significant fluid leakage from the site. The dressing should be monitored for any signs of infection or excessive drainage, but a dry puncture site is generally a positive sign of proper healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The arterial blood gas (ABG) values of pH 7.26, HCO₃ 14, and PaCO₂ 30 indicate metabolic acidosis with partial respiratory compensation. Acute kidney injury (AKI) often leads to metabolic acidosis due to the kidneys’ inability to excrete acid and reabsorb bicarbonate. The low pH indicates acidosis, the low bicarbonate (HCO₃) reflects metabolic acidosis, and the low PaCO₂ shows that the respiratory system is trying to compensate by blowing off CO₂.
Choice B reason:
The ABG values of pH 7.49, HCO₃ 30, and PaCO₂ 40 indicate metabolic alkalosis. This condition is characterized by an elevated pH and bicarbonate level. Metabolic alkalosis is not typically associated with acute kidney injury. Instead, it can result from excessive bicarbonate intake, loss of gastric acid (e.g., vomiting), or diuretic use.
Choice C reason:
The ABG values of pH 7.26, HCO₃ 24, and PaCO₂ 46 suggest respiratory acidosis. The low pH indicates acidosis, but the normal bicarbonate level and elevated PaCO₂ point to a respiratory cause rather than a metabolic one. Respiratory acidosis occurs when the lungs cannot remove enough CO₂, leading to its accumulation. This is not a typical presentation of AKI.
Choice D reason:
The ABG values of pH 7.49, HCO₃ 24, and PaCO₂ 30 indicate respiratory alkalosis. The high pH and low PaCO₂ suggest that the patient is hyperventilating, leading to excessive CO₂ loss. This condition is not commonly associated with acute kidney injury, which more frequently causes metabolic acidosis.
Correct Answer is D
Explanation
Choice A reason:
Measuring a client’s intake and output (I&O) is a task that can be performed by assistive personnel (AP). This task involves recording the amount of fluids a client consumes and excretes, which does not require the specialized skills of an LPN. Therefore, it is more appropriate to assign this task to the AP.
Choice B reason:
Obtaining a client’s weight is another task that can be delegated to assistive personnel (AP). This task involves using a scale to measure the client’s weight and recording the result. It is a routine task that does not require the advanced training of an LPN.
Choice C reason:
Providing postmortem care for a client can be performed by assistive personnel (AP) under the supervision of an RN or LPN. This task involves preparing the body after death, which includes cleaning and positioning the body. While LPNs can perform this task, it is not exclusive to their scope of practice and can be delegated to AP.
Choice D reason:
Inserting a nasogastric tube for a client is a task that requires the specialized skills and training of an LPN. This procedure involves inserting a tube through the client’s nose into the stomach, which requires knowledge of anatomy, sterile technique, and the ability to assess for complications. Therefore, this task should be assigned to the LPN.
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