Increased heart rate.
Discomfort at the puncture site.
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?
Decreased temperature.
Serosanguineous drainage from the puncture site.
Shortness of breath.
Chest pain.
The Correct Answer is C
Choice A rationale
Decreased temperature is not typically an immediate complication following a thoracentesis. It may indicate an infection, but this would develop over time rather than immediately after the procedure.
Choice B rationale
Serosanguineous drainage from the puncture site is expected after a thoracentesis and does not indicate a complication that requires immediate attention.
Choice C rationale
Shortness of breath is a serious complication that can indicate a pneumothorax or re- accumulation of fluid in the pleural space. This requires immediate attention and intervention by the healthcare provider.
Choice D rationale
Chest pain can be a sign of a complication such as a pneumothorax or infection. However, shortness of breath is a more immediate and severe symptom that requires urgent attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Take temperature weekly. This statement is incorrect. Clients with neutropenia should monitor their temperature daily, not weekly, because they are at high risk for infections. A fever can be an early sign of infection, and prompt detection is crucial for timely treatment.
Choice B rationale
Perform mild exercise, such as gardening. This statement is incorrect. While mild exercise can be beneficial, activities like gardening can expose neutropenic clients to soil and plants that may harbor bacteria and fungi, increasing the risk of infection.
Choice C rationale
Avoid crowds. This statement is correct. Neutropenic clients are highly susceptible to infections due to their weakened immune systems. Avoiding crowded places reduces the risk of exposure to pathogens that can cause infections.
Choice D rationale
Eat plenty of fresh fruits and vegetables. This statement is incorrect. While fresh fruits and vegetables are generally healthy, they can harbor bacteria and other pathogens that pose a risk for neutropenic individuals. It is often recommended that neutropenic clients eat cooked or canned fruits and vegetables instead.
Correct Answer is A
Explanation
Choice A rationale
Hypovolemic shock occurs due to a significant decrease in circulating blood volume, leading to inadequate tissue perfusion. Blood loss, such as the 800 mL lost during surgery, is a common cause of hypovolemic shock. The steadily decreasing blood pressure is consistent with this type of shock.
Choice B rationale
Septic shock results from a systemic inflammatory response to infection, leading to vasodilation and maldistribution of blood flow. There is no indication of infection in this scenario.
Choice C rationale
Neurogenic shock results from a loss of sympathetic tone, leading to vasodilation and relative hypovolemia. It is often associated with spinal cord or severe head injury, which is not indicated in this scenario.
Choice D rationale
Obstructive shock occurs when there is an obstruction to blood flow within the cardiovascular system, such as a pulmonary embolism or cardiac tamponade. There is no evidence of such an obstruction in this scenario.
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