A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

Discomfort at the puncture site

Serosanguineous drainage from the puncture site

Increased heart rate

Decreased temperature

Answer and Explanation

The Correct Answer is C

A. Discomfort at the puncture site:
Some discomfort at the puncture site is normal after a thoracentesis. It may be managed with pain medication as needed.

B. Serosanguineous drainage from the puncture site:
Serosanguineous drainage (a mix of clear and bloody fluid) is a common and expected finding after a thoracentesis. It is part of the normal post-procedure care.

C. Increased heart rate
Increased heart rate can be indicative of a complication following a thoracentesis, such as a pneumothorax or bleeding. This requires immediate attention, and the healthcare provider should be contacted promptly for further evaluation and intervention.

D. Decreased temperature:
A decreased temperature alone is not typically associated with complications following a thoracentesis. It may be related to other factors, but it is not an immediate concern compared to an increased heart rate.

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Correct Answer is B

Explanation

A. Elevate the client’s head of bed:
Elevating the head of the bed is a good practice for patients on mechanical ventilation as it helps prevent complications such as aspiration. However, in the scenario where the client has pulled out the endotracheal tube, the immediate concern is assessing the airway and ensuring adequate oxygenation and ventilation. Elevating the head of the bed can be done later as needed.

B. Assess the client’s airway:
This is the correct and priority action. The nurse should assess the client's airway first to determine the extent of the situation. This involves checking for signs of airway obstruction, respiratory distress, or inadequate oxygenation. The assessment guides subsequent interventions.

C. Prepare the client for intubation:
While preparing for intubation may be necessary if the endotracheal tube is completely displaced, assessing the airway comes first. The nurse needs to gather information about the client's current condition before deciding on the appropriate course of action.

D. Suction the client’s mouth:
Suctioning may be necessary, especially if there are secretions or other obstructions in the mouth or airway. However, it should come after the initial assessment of the airway. If the client's airway is clear, suctioning may not be the immediate priority.

A. Loop the tubing of the chest tube on the client’s bed. B. Strip the client’s chest tube every 2 hrs. C. Place the chest tube drainage system below the level of the client’s heart. D. Tape the connections on the client’s chest tube.

Correct Answer is C

Explanation

A. Loop the tubing of the chest tube on the client’s bed:
Looping the tubing may create dependent loops that can trap drainage and prevent effective functioning of the chest tube. It can impede the drainage of air or fluid from the pleural space.

B. Strip the client’s chest tube every 2 hrs:
Stripping or milking the chest tube is an outdated practice. It can cause trauma to the tissue surrounding the chest tube and increase the risk of complications, including damage to the lung tissue or tubing.

C. Place the chest tube drainage system below the level of the client’s heart:
This is the correct action. Placing the chest tube drainage system below the level of the client's chest allows gravity to assist with drainage and prevents backflow or accumulation of fluids within the chest tube.

D. Tape the connections on the client’s chest tube:
Taping the connections on the chest tube is not recommended. It is important to keep connections secure, but taping can make it difficult to quickly identify and address any issues with the chest tube system during monitoring and assessment.

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A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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