The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)

Decreased lung sounds

Heart rate 110/min and regular

Oxygen saturation of 95%

Subcutaneous emphysema

Trachea midline

Puncture site dry

Answer and Explanation

Correct Answer : A,D

A. Decreased lung sounds
A decrease in lung sounds could indicate a pneumothorax, which is a potential complication of thoracentesis. It requires prompt evaluation.

B. Heart rate 110/min and regular
A heart rate of 110/min is within a normal range, and regular rhythm is generally acceptable post-thoracentesis. It may be related to pain or anxiety but is not an immediate concern.

C. Oxygen saturation of 95%
An oxygen saturation of 95% is within an acceptable range. While maintaining adequate oxygenation is important, this finding does not suggest an immediate complication.

D. Subcutaneous emphysema
Subcutaneous emphysema involves the presence of air in the subcutaneous tissues and can indicate a communication between the pleural space and subcutaneous tissues. This requires immediate attention.

E. Trachea midline
The trachea being midline is a normal finding and does not indicate an immediate problem post-thoracentesis.

F. Puncture site dry
A dry puncture site is expected after a thoracentesis. This finding is normal and indicates appropriate wound care. It is included in the list to ensure recognition of normal post-procedure findings.

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Correct Answer is A

Explanation

A. The patient’s paralyzing agent dose is adequate, but needs to be given more often.
In a Train-of-four (TOF) assessment, four stimuli are delivered in rapid succession, and the response is observed. The number of twitches in the patient's thumb indicates the degree of neuromuscular blockade. In this case, if the patient's thumb twitches three times, it suggests that there is still some residual neuromuscular blockade, and the paralyzing agent dose is adequate. However, the frequency of administration may need to be increased to maintain the desired level of paralysis or neuromuscular blockade.

B. The patient’s paralyzing agent dose is too low and needs to be increased:
This would be indicated if there were fewer than three twitches in response to the TOF assessment.

C. The patient’s paralyzing agent dose is appropriate and does not need to be changed:
The response of three twitches suggests that there is still some neuromuscular blockade, so the dose or frequency may need adjustment.

D. The patient’s paralyzing agent dose is too high and needs to be reduced:
If there were no twitches or a complete absence of twitches, this might suggest an excessive dose. However, three twitches indicate some degree of neuromuscular blockade.

A. An increase in the CMV rate B. Change to SIMV MODE C. A decrease in The PaO2 D. A decrease in the CMV rate

Correct Answer is B

Explanation

A. An increase in the CMV rate:
Increasing the continuous mandatory volume (CMV) rate would provide more mandatory breaths, which may not address the patient's respiratory acidosis. It could potentially worsen the situation by causing respiratory alkalosis.

B. Change to SIMV (Synchronized Intermittent Mandatory Ventilation) MODE
The patient's arterial blood gas results indicate respiratory acidosis with an elevated PaCO2 (50 mmHg) and a low pH (7.30). The nurse would recommend changing to SIMV mode to allow for spontaneous breaths in addition to the set mandatory breaths. This change helps the patient to have more control over their respiratory efforts and may assist in lowering the PaCO2.

C. A decrease in the PaO2:
Decreasing the partial pressure of oxygen (PaO2) is not an appropriate response, especially when the patient is already on mechanical ventilation and has a moderate PaO2 level. The primary concern is the elevated PaCO2 and respiratory acidosis.

D. A decrease in the CMV rate:

Decreasing the CMV rate would reduce the number of mandatory breaths, potentially allowing the patient to hypoventilate further and retain more carbon dioxide. This is not the appropriate intervention for a patient with respiratory acidosis.

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The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with acute respiratory distress syndrome is receiving a paralyzing agent. With a Train-of-four (TOF) assessment, the patient’s thumb twitches 3 times. How would the nurse interpret this response?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse’s priority?

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The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

A nurse is assessing a client who has oxygen toxicity. Which of the following findings should the nurse expect?

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A nurse is preparing to administer dextrose 5% in water (DW) 150 mL IV to infuse over 3 hr. The drop factor of the manual IV tubing is 10 gtt. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do not use a trailing zero.)

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?

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO: 68 mm Hg Base excess-2 Pa0: 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L