The day shift practical nurse (PN) is performing a focused assessment on a client who had a thoracentesis the evening before. The PN should alert the healthcare provider if the client exhibits which finding?

Rationale:

A. Note sputum characteristics: Documenting the color, consistency, and amount of sputum provides valuable information about potential respiratory infection or inflammation. However, it is not the immediate priority because it does not directly indicate the client’s current physiological stability.

B. Monitor white blood cell count: An elevated WBC count can suggest infection, but laboratory results may not be immediately available. This information supports assessment but does not provide real-time data about the client’s acute status.

C. Measure vital signs: Vital signs offer immediate and objective data on the client’s respiratory and cardiovascular status, including heart rate, respiratory rate, oxygen saturation, and temperature. Given a productive cough, monitoring for fever, tachypnea, or hypoxia is critical to identify acute deterioration and guide prompt intervention.

D. Assess for dependent edema: Checking for edema can indicate fluid overload or cardiac compromise, but in the context of a productive cough, respiratory status takes priority over circulatory findings. Edema assessment is important but not the first action in this scenario.

Rationale:

A. Inquire about the impact on activities of daily living: Visual acuity of 20/40 and 20/30 indicates reduced distance vision, particularly affecting tasks such as driving, reading signs, or recognizing faces at a distance. Assessing how this impairment affects the client’s daily functioning helps determine the clinical significance and need for intervention.

B. Document the findings are within normal limits in the medical record: Normal visual acuity is 20/20, and values of 20/30 and 20/40 represent diminished visual clarity. Documenting these findings as normal would be inaccurate and could delay appropriate evaluation or intervention. Proper interpretation of the Snellen test is essential for safe clinical decision-making.

C. Move the client until 10 feet away from the chart: The Snellen chart is standardized for use at a distance of 20 feet (or equivalent using mirrors), ensuring consistency and validity of results. Changing the testing distance to 10 feet without appropriate calibration alters the accuracy of the measurement and invalidates the assessment.

D. Encourage the client to schedule an appointment with an ophthalmologist: Referral to an eye specialist may eventually be appropriate, especially if visual impairment affects function. However, the nurse should first assess the impact on the client’s daily activities to determine urgency and guide appropriate follow-up care.