A nurse is caring for a client who had a thoracentesis 2 hr ago. Which of the following findings should the nurse expect?
Increased lung expansion
Rapid, shallow respirations
Crepitus at the puncture site
Dry, nonproductive cough
The Correct Answer is A
A. Increased lung expansion: Thoracentesis removes excess fluid from the pleural space, allowing the affected lung to re-expand more fully. Improved lung expansion is an expected therapeutic outcome within a few hours after the procedure, leading to easier breathing and improved ventilation.
B. Rapid, shallow respirations: Rapid, shallow breathing may indicate respiratory distress or complications such as pneumothorax. This is not an expected finding and would require immediate evaluation. Its presence suggests impaired gas exchange rather than improvement after fluid removal.
C. Crepitus at the puncture site: Crepitus indicates subcutaneous emphysema, which can occur if air leaks into the tissue during the procedure. This is an abnormal finding and may signal a pneumothorax or injury to lung tissue, requiring prompt provider notification.
D. Dry, nonproductive cough: While a mild, transient cough may occur immediately after the procedure due to the change in intrathoracic pressure, a persistent or new, dry cough could indicate continued irritation or developing pleural complications, though less critical than the signs of pneumothorax.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Calcium gluconate: This medication is used to treat conditions such as hypocalcemia or magnesium toxicity and has no role in reversing opioid-induced respiratory depression. Its effects do not impact opioid receptors or respiratory drive.
B. Naloxone: Naloxone is an opioid antagonist that rapidly reverses opioid-induced respiratory depression by displacing opioids from receptor sites. It restores ventilation within minutes and is the primary treatment for acute opioid toxicity in postoperative settings.
C. Diphenhydramine: This antihistamine is used for allergic reactions or as a sedative but can worsen CNS depression. It offers no therapeutic benefit for treating respiratory depression caused by morphine.
D. Flumazenil: Flumazenil reverses benzodiazepine-induced sedation, not opioid effects. Administering flumazenil would not improve respiratory status in a client experiencing opioid-related complications.
Correct Answer is B
Explanation
A. Fever: Fever is a systemic sign of infection that may occur after peritonitis has progressed. While important to monitor, it is not typically the earliest indication of peritoneal infection in clients performing dialysis.
B. Cloudy effluent: Cloudy effluent is often the first sign of peritonitis in peritoneal dialysis clients. It reflects the presence of white blood cells or bacteria in the dialysate and allows early detection and prompt treatment of infection.
C. Generalized abdominal pain: Abdominal pain can occur with peritonitis, but it usually develops after the initial inflammatory process begins. Pain is a later manifestation compared with changes in dialysate appearance.
D. Increased heart rate: Tachycardia can be a secondary response to infection or systemic inflammation, but it does not serve as an early indicator. Monitoring effluent clarity provides the most immediate evidence of peritoneal infection.
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