A patient with a medical history of COPD is admitted with pneumonia with a right-sided pleural effusion. At 1130 the patient returns to the unit after a thoracentesis. Which assessment finding is the highest priority?
Respiratory rate of 28
Pain 10/10 at the procedural site
Blood pressure 102/56
O2 saturation 93% on 2L/NC
The Correct Answer is A
A. Respiratory rate of 28: An elevated respiratory rate is the highest priority because it indicates possible respiratory distress or compromise, which can occur after thoracentesis due to lung re-expansion, pneumothorax, or hypoxemia. Rapid assessment and intervention are needed to prevent further deterioration and ensure adequate ventilation.
B. Pain 10/10 at the procedural site: Severe pain is concerning and requires prompt management, but pain alone is not immediately life-threatening. While analgesia should be provided, respiratory status takes precedence in prioritization.
C. Blood pressure 102/56: Mild hypotension may be present post-procedure due to fluid shifts or sedation, but this blood pressure is not immediately critical in comparison to signs of respiratory compromise. Monitoring and supportive care are important but secondary to airway and breathing assessment.
D. O2 saturation 93% on 2L/NC: While slightly below optimal oxygen saturation, this value is less urgent than the elevated respiratory rate, which may indicate compensatory mechanisms or early deterioration. Continuous monitoring and supplemental oxygen are appropriate, but priority is rapid assessment of respiratory effort and airway patency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Change the chest tube drainage system: Replacing the entire drainage system may be necessary if it is malfunctioning, but this is not the first action. Immediate assessment is required to determine the cause of the sudden decrease in drainage before taking corrective steps.
B. Increase the suction pressure on the chest tube drainage system: Adjusting suction without understanding the reason for decreased drainage could worsen the situation or create unnecessary negative pressure. Suction adjustments should only be made after identifying the underlying issue.
C. Assess the tubing of the chest tube and drainage system: The first action is to inspect the tubing for kinks, clots, disconnections, or obstructions, which are the most common causes of sudden decreased drainage. Ensuring the system is intact and functional preserves lung re-expansion and prevents complications.
D. Call the provider immediately to report the decrease in drainage: Reporting to the provider is important if a problem is identified, but the nurse must first assess and gather information about the situation. Immediate assessment provides critical data for accurate reporting and timely intervention.
Correct Answer is B
Explanation
A. Adenosine 6 mg IV: The provided rhythm strip shows clear ST-segment elevation. Adenosine is used to treat paroxysmal supraventricular tachycardia (PSVT) by temporarily blocking AV node conduction. It is not indicated for acute ST-elevation myocardial infarction (STEMI) and would not address the patient’s ischemic chest pain.
B. Nitroglycerin 0.4 mg sublingual: Sublingual nitroglycerin is the priority medication for immediate relief of ischemic chest pain in acute coronary syndrome, including STEMI. It dilates coronary arteries, improves myocardial oxygen supply, and reduces preload and myocardial oxygen demand, which directly targets the patient’s presenting symptoms.
C. Metoprolol 5 mg IV: Metoprolol, a beta-blocker, can reduce heart rate, myocardial oxygen demand, and blood pressure in acute coronary syndrome. While important in STEMI management, it is not the first-line priority for immediate pain relief; pain and myocardial perfusion take precedence.
D. Ondansetron 4 mg sublingual: Ondansetron is an antiemetic used to relieve nausea. While helpful for patient comfort, it does not address myocardial ischemia or reduce cardiac workload, and is therefore not a priority in the acute management of STEMI.
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