The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?

Dullness bilaterally on percussion.

Serosanguinous drainage from the chest tube.

Diminished breath sounds in the left lower lobe.

Mediastinal shift to the right.

Answer and Explanation

The Correct Answer is D

A)   Incorrect- Dullness bilaterally on percussion is not a normal finding, but it is not an immediate concern after thoracentesis. It may indicate fluid accumulation or consolidation in both lungs, which could be related to other conditions such as pneumonia or heart failure.
B)   Incorrect- Serosanguinous drainage from the chest tube is expected after thoracentesis, as long as it is not excessive or continuous. The nurse should monitor the amount and color of the drainage and document it accordingly.
C)   Incorrect- Diminished breath sounds in the left lower lobe are also expected after thoracentesis, as the procedure removes fluid and air from the pleural space and reduces lung expansion. The nurse should auscultate the lungs before and after the procedure and compare the findings. The breath sounds should improve gradually as the lung re-expands.
D)   Correct- This is a sign of tension pneumothorax, which is a life-threatening complication of thoracentesis. Tension pneumothorax occurs when air accumulates in the pleural space and creates positive pressure that pushes the mediastinum (the heart, great vessels, and trachea) to the opposite side of the chest. This can impair venous return, cardiac output, and respiratory function. The nurse should report this finding to the healthcare provider immediately and prepare to assist with needle decompression or chest tube insertion.

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Correct Answer is C

Explanation

Orlistat is a weight-control medication that works by inhibiting the absorption of dietary

fats in the intestines. It can also interfere with the absorption of fat-soluble vitamins (such as vitamins A, D, E, and K) and beta-carotene. Therefore, it is important for the client to take a multivitamin supplement to ensure an adequate intake of these essential nutrients.

However, it is recommended to take the multivitamin and orlistat at least two hours apart. This is because orlistat can potentially interfere with the absorption of the

fat-soluble vitamins in the multivitamin if taken simultaneously. By spacing them apart, the client can optimize the absorption of both the medication and the multivitamin.

Multivitamins are not contraindicated during treatment with orlistat. In fact, they are often recommended to compensate for potential nutrient deficiencies.

While orlistat may contain some vitamins and minerals, it does not provide all the recommended daily amounts. Therefore, additional supplementation may be necessary. While following a well-balanced diet is indeed important for good nutrition, it does not address the need for specific nutrient supplementation when taking orlistat. Both a balanced diet and appropriate vitamin supplementation can be beneficial in this situation.

A. Drank a glass of water in the past 2 hours. B. Reports left chest wall pain prior to admission. C. Experiences facial swelling after eating crab. D. Verbalizes a fear of being in a confined space.

Correct Answer is C

Explanation

The correct answer is: C. Experiences facial swelling after eating crab.

Choice A Reason: Drinking a glass of water in the past 2 hours is not typically a concern unless the patient has been instructed to fast. For most cardiac catheterization procedures, patients are asked to fast for a certain period before the procedure to reduce the risk of aspiration. However, small sips of water may be allowed with medications.

Choice B Reason: While reports of left chest wall pain are clinically significant and warrant investigation, they are not as immediately concerning for the angioplasty procedure itself. Chest pain is a symptom that may have led to the decision to perform angioplasty but does not pose an immediate risk of complication during the procedure as an allergy might.

Choice C Reason: As previously mentioned, experiencing facial swelling after eating crab is indicative of a shellfish allergy. This is important because the contrast dye used in angioplasty may contain iodine, and patients with shellfish allergies could have an increased risk of an allergic reaction to the iodine in the dye. It is essential to explore this further to take necessary precautions, such as premedication with antihistamines or using a different contrast agent.

Choice D Reason: Verbalizing a fear of being in a confined space, or claustrophobia, is a psychological concern that should be addressed to ensure the patient’s comfort during the procedure. However, it does not pose a direct risk to the safety of the angioplasty procedure like an allergic reaction does. Managing patient anxiety is important, but it is not the most critical factor to explore prior to the procedure.

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The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client plans to take a multivitamin. Which teaching should the nurse provide?

Correct Answer is C

Explanation

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

Correct Answer is C

Explanation

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