Lung Cancer with Thoracentesis
A nurse is caring for a 75-year-old male client in the medical-surgical unit who is experiencing difficulty breathing and shortness of breath following a thoracentesis.
The nurse is caring for the client following a thoracentesis. Select the 3 findings that require immediate follow-up.
Decreased lung sounds
Puncture site dry
Subcutaneous emphysema
Oxygen saturation of 95%
Correct Answer : A,C,D
Choice A rationale: Decreased lung sounds following thoracentesis may indicate a pneumothorax, especially when combined with other signs such as shortness of breath or changes in respiratory effort. Pneumothorax is a known complication post-thoracentesis due to lung collapse or puncture. Immediate assessment and chest x-ray are needed to rule this out. Lung sounds should improve after fluid removal, not diminish, making this a critical finding requiring follow-up.
Choice B rationale: A dry puncture site is an expected and normal finding following thoracentesis. It indicates that there is no ongoing fluid or air leakage from the site. The integrity of the dressing and absence of drainage suggest proper wound healing and that the procedure was done correctly. This finding does not require immediate follow-up and is actually a sign of stable post-procedural status.
Choice C rationale: Subcutaneous emphysema indicates air has leaked into the subcutaneous tissue, often from the pleural space due to lung injury or puncture. It presents as swelling and a crackling sensation under the skin and is a potential sign of pneumothorax. It must be followed up immediately because it may progress or indicate a more serious underlying pulmonary complication that requires prompt evaluation and potential intervention.
Choice D rationale: An oxygen saturation of 95% is generally acceptable in most patients, but in this specific context—post-thoracentesis in a patient with a history of lung cancer and repeated pleural effusions—this value could mask early respiratory compromise. The patient initially had a saturation of 91%, and although this improved, the presence of ongoing respiratory symptoms like labored breathing or other abnormal signs warrants close monitoring and possibly further evaluation to ensure respiratory stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
An abdominal aortic aneurysm (AAA) involves a localized dilation of the abdominal aorta. Early manifestations often include lower back or groin pain, which results from the pressure exerted by the expanding aneurysm on adjacent spinal nerves or surrounding retroperitoneal structures. This referred pain is a direct consequence of mechanical compression and irritation of nerve roots originating from the lumbar or sacral plexuses.
Choice B rationale
Pain in the chest is typically associated with thoracic aortic aneurysms or cardiac conditions such as myocardial infarction or angina, not primarily with abdominal aortic aneurysms. While a very large and dissecting AAA could potentially cause referred pain upwards, it is not an early or characteristic chest pain presentation for an AAA.
Choice C rationale
Cullen's sign, periumbilical ecchymosis, indicates retroperitoneal bleeding, often associated with pancreatitis or ruptured ectopic pregnancy. While a ruptured AAA can cause significant retroperitoneal hemorrhage and potentially Cullen's sign, it is a late and severe sign of rupture, not an early manifestation of an intact AAA.
Choice D rationale
Hunger after eating is a gastrointestinal symptom often related to metabolic or digestive issues, such as rapid gastric emptying or insufficient satiety mechanisms. It has no direct physiological correlation with the development or early manifestations of an abdominal aortic aneurysm, which is a vascular condition.
Correct Answer is A
Explanation
Choice A rationale
Acetaminophen is an appropriate analgesic for post-cardiac catheterization discomfort in children. It provides effective pain relief without affecting platelet function or increasing the risk of bleeding, unlike NSAIDs. Maintaining comfort is crucial for promoting rest and preventing agitation, which could dislodge the catheter site clot and lead to hemorrhage from the arterial access site.
Choice B rationale
Offering clear liquids for the first 24 hours is an overly restrictive dietary instruction for a 10-year-old following a cardiac catheterization. Unless there are specific contraindications, the child can typically resume a regular diet once they are fully awake and tolerate oral fluids. Prolonged clear liquid diets can lead to inadequate caloric intake and discomfort.
Choice C rationale
Keeping the child home for 1 week after a cardiac catheterization is generally unnecessary for an uncomplicated procedure. While strenuous activity should be restricted for a few days to prevent bleeding at the puncture site, most children can return to school and light activities within 2-3 days, depending on individual recovery and provider recommendations.
Choice D rationale
Assisting the child to take a tub bath for the first 3 days is contraindicated after a cardiac catheterization. Immersion in water can increase the risk of infection at the puncture site due to bacterial contamination from bathwater. Showering is generally permitted, with instructions to keep the dressing dry and avoid scrubbing the site, but tub baths should be avoided.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.