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. Suppress respiratory effort
Pancuronium is a neuromuscular blocking agent that is often used to induce paralysis in patients requiring mechanical ventilation. It works by blocking the transmission of nerve impulses at the neuromuscular junction, leading to skeletal muscle paralysis. In the context of a client with acute respiratory distress syndrome (ARDS) on mechanical ventilation, the use of pancuronium helps to suppress respiratory effort, allowing for better control of the patient's ventilation and oxygenation.

B. Decrease chest wall compliance:
Pancuronium does not directly affect chest wall compliance. It primarily acts on skeletal muscles, leading to paralysis.

C. Decrease respiratory secretions:
Pancuronium is not used to decrease respiratory secretions. It is a neuromuscular blocking agent with the main goal of inducing paralysis.

D. Induce sedation:
Pancuronium does not induce sedation. It works on the neuromuscular junction and does not have sedative properties. Sedation may be achieved with other medications, such as sedative agents.

Correct Answer is ["8"]

Explanation

To calculate the infusion rate for the IV solution, the nurse needs to use the formula:

Infusion rate (gtt/min) = Volume (mL) x Drop factor (gtt/mL) / Time (min)

Plugging in the given values, we get:

Infusion rate (gtt/min) = 150 mL x 10 gtt/mL / 180 min

Simplifying, we get:

Infusion rate (gtt/min) = 8.33 gtt/min

Since the answer needs to be rounded to the nearest whole number, the final answer is:

Infusion rate (gtt/min) = 8 gtt/min

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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 nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?

Correct Answer is A

Explanation

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.)

Correct Answer is ["8"]

Explanation

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