A nurse is caring for a client who had a thoracentesis 2 hr ago. Which of the following findings should the nurse expect?
Crepitus at the puncture site
Dry, nonproductive cough
Increased lung expansion
Rapid, shallow respirations
The Correct Answer is C
Rationale:
A. Crepitus at the puncture site: Crepitus, or the sensation of air under the skin, may indicate subcutaneous emphysema, which is a complication that can occur after thoracentesis. It is not a normal finding and should be reported immediately.
B. Dry, nonproductive cough: A dry, nonproductive cough is not a typical finding immediately following thoracentesis. Coughing may be associated with post-procedure irritation but should not be expected as a common outcome.
C. Increased lung expansion: Increased lung expansion is the desired outcome after thoracentesis. The procedure removes excess pleural fluid, allowing the lung to expand more fully. This is a positive result that should be expected as the client recovers.
D. Rapid, shallow respirations: Rapid, shallow respirations can indicate respiratory distress, which could signal a complication such as pneumothorax. This is not an expected finding and requires immediate evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "You should use an incentive spirometer every 8 hours." Using an incentive spirometer is important for preventing respiratory complications, but the recommendation should be to use it every 1-2 hours while awake, not just every 8 hours.
B. "Clean the incision daily with hydrogen peroxide." Hydrogen peroxide is too harsh for wound care and can delay healing by damaging new tissue. The incision should be cleaned with mild soap and water or as directed by the healthcare provider.
C. "You can cross your legs at the ankles when sitting down." After a hip replacement, clients should avoid crossing their legs, especially at the knees, to prevent dislocation of the new hip joint.
D. "Install a raised toilet seat in your bathroom." After hip replacement surgery, the client should avoid bending the hip beyond 90 degrees to reduce the risk of dislocation. Installing a raised toilet seat helps the client maintain proper positioning and avoid hip flexion beyond the recommended limit.
Correct Answer is D
Explanation
Rationale:
A. "I am sure you will be able to still spend time with your grandchildren." While reassurance is important, this statement may not be realistic, and it does not acknowledge the client’s feelings of uncertainty. The client may need more support and guidance regarding their post-surgery recovery and limitations.
B. "Why do you think you won't be able to play with your grandchildren?" This question may sound confrontational or dismissive of the client’s concerns. It is more important to validate the client’s emotions and explore their feelings in a non-judgmental way..
C. "You will not be as active for a couple of years." This statement is overly negative and does not provide an opportunity to explore the client’s emotional needs. Recovery from knee arthroplasty varies and focusing on long-term inactivity could discourage the client.
D. "What are some of the activities you like to do with your grandchildren?" This open-ended question validates the client’s feelings and helps shift the focus towards their interests and goals. It allows the nurse to explore realistic expectations and discuss ways to resume activities after recovery, fostering a positive outlook.
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