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.

Choice A reason:

Providing a list of the client’s current medications during the change of shift report is important for continuity of care, but it is not the primary focus of medication reconciliation. Medication reconciliation aims to ensure accuracy of the medication list at key transition points, such as admission, transfer, and discharge.

Choice B reason:

Not performing reconciliation for a client at discharge from a health care facility is incorrect. Medication reconciliation is crucial at discharge to ensure that the patient leaves with an accurate and complete list of medications, which helps prevent medication errors and adverse drug events.

Choice C reason:

Providing a list of the client’s current medications during admission to a health care facility is a key component of medication reconciliation. This process involves comparing the patient’s current medications with the new medications ordered upon admission to identify and resolve any discrepancies. This helps ensure that the patient receives the correct medications throughout their stay.

Choice D reason:

Including only prescription medications in the medication reconciliation report is insufficient. The reconciliation process should include all medications the patient is taking, including over-the-counter drugs, supplements, and herbal remedies. This comprehensive approach helps identify potential interactions and ensures safe medication management.