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.

Oxygen saturation of 95%

Heart rate 110/min and regular

Puncture site dry

Subcutaneous emphysema

Trachea midline

Decreased lung sounds

Answer and Explanation

Correct Answer : B,D,F

A. Oxygen saturation of 95%. While oxygen saturation has improved after thoracentesis, it is within an acceptable range and does not require immediate intervention. However, continuous monitoring is necessary to detect any decline.
B. Heart rate 110/min and regular. Tachycardia can indicate hypovolemia, respiratory distress, or a developing pneumothorax following the removal of a large amount of pleural fluid. The nurse should assess for additional signs of distress and notify the provider if it persists or worsens.
C. Puncture site dry. A dry puncture site is an expected finding, indicating no active bleeding or fluid leakage from the procedure. This does not require immediate followup.
D. Subcutaneous emphysema.The presence of air under the skin suggests a possible lung puncture or air leak into the subcutaneous tissue. This finding requires immediate assessment to rule out a pneumothorax, which may necessitate further intervention such as chest tube placement.
E. Trachea midline. A midline trachea indicates that there is no significant shift in mediastinal structures, ruling out severe pneumothorax or tension pneumothorax. This is a reassuring finding and does not require urgent action.
F. Decreased lung sounds. A reduction in lung sounds on the affected side can indicate lung collapse, reaccumulation of pleural fluid, or pneumothorax following thoracentesis. This requires immediate followup to assess for respiratory compromise and possible imaging to confirm the underlying cause.

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Correct Answer is A

Explanation

A. Protamine sulfate is the specific antidote for heparin toxicity, working by neutralizing heparin’s anticoagulant effects. It binds to heparin to form a stable complex, preventing excessive bleeding. It is administered intravenously (IV) in cases of heparin overdose or severe bleeding complications.
B. Vitamin K is the antidote for warfarin (Coumadin), not heparin. It promotes the synthesis of clotting factors II, VII, IX, and X, but it does not affect heparin’s mechanism of action, which works by inhibiting thrombin and factor Xa.
C. Deferasirox is an iron chelating agent used to treat iron overload in conditions like thalassemia or hemochromatosis. It does not reverse anticoagulation caused by heparin.
D. Acetylcysteine is primarily used to treat acetaminophen (Tylenol) overdose and as a mucolytic for respiratory conditions. It has no role in counteracting heparin’s effects.

A. Firstdegree heart block B. Atrial fibrillation C. Sinus bradycardia D. Supraventricular tachycardia

Correct Answer is B

Explanation

A. Firstdegree heart block is characterized by a prolonged PR interval (>0.20 seconds) while maintaining a regular rhythm. In this case, the PR interval is unmeasurable, and the rhythm is irregular, making firstdegree heart block unlikely.
B. Atrial fibrillation (AFib) is the most accurate interpretation. Key characteristics of AFib include:Irregular rhythm (hallmark finding), absent P waves (due to disorganized atrial electrical activity), unmeasurable PR interval and narrow QRS complex (typically <0.12 seconds). In AFib, the atria quiver instead of contracting effectively, leading to an irregularly irregular rhythm with no identifiable P waves.
C. Sinus bradycardia is characterized by a regular rhythm, a heart rate below 60/min, visible P waves, and a measurable PR interval. This does not match the irregular rhythm and absent P waves seen in this case.
D. Supraventricular tachycardia (SVT) typically presents with a regular, rapid rhythm (>150/min), narrow QRS complex, and absent or hidden P waves. The client’s heart rate of 92/min is not in the tachycardic range, ruling out SVT.

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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.

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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.