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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Pain in the affected leg could indicate worsening of cellulitis or a potential complication like deep vein thrombosis (DVT), but there is no immediate indication of a life-threatening condition. This client should be assessed, but may not be the top priority unless other signs of complications are present.

B. A serum calcium level of 10 mg/dL is within the normal range (8.5 to 10.5 mg/dL). A headache, while concerning, is not immediately life-threatening unless there are additional symptoms suggesting something more severe.

C.Reddish brown urine suggests hematuria, a symptom of glomerulonephritis. This could indicate ongoing kidney issues, but unless there are signs of severe kidney failure or systemic infection, this might not be the most urgent case.

D. A blood glucose level of 68 mg/dL is low and can lead to hypoglycemia, which can be immediately life-threatening if it progresses to severe hypoglycemia. Symptoms of hypoglycemia include confusion, dizziness, sweating, and can escalate to seizures or unconsciousness if not promptly treated.

A. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post meal capillary blood glucose is now 160 mg/dL B. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 D. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous

Correct Answer is B

Explanation

A. A client who has a prescription for insulin, and his premeal capillary blood glucose was 110 mg/dL, and his post-meal capillary blood glucose is now 160 mg/dL:
While changes in blood glucose levels are important to monitor, the described change is not as significant as a sudden drop in blood pressure. The blood glucose levels in this scenario are still within a reasonable range.

B. A client whose blood pressure at 0800 was 138/86 mm Hg, and at 1200 is 106/60 mm Hg:
This is the priority client. The significant drop in blood pressure raises concerns about hypovolemia or circulatory issues, which require immediate attention to prevent complications such as inadequate organ perfusion.

C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 and now reports pain as 6:
Pain management is important, but the change in pain intensity from 4 to 6, while indicating an increase, may not be as urgent as addressing a significant drop in blood pressure. Pain assessment and management can be addressed after stabilizing the client with the acute change.

D. A client whose wound drainage at 0800 was sanguineous, and now it is serosanguineous:
Changes in wound drainage color can be important for assessing the healing process, but a shift from sanguineous to serosanguineous is generally within the expected progression of wound healing. It may not require immediate intervention as compared to a significant drop in blood pressure.

View Question and Answer

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

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 has received morning report on the following four clients. Which of the following clients should the nurse assess first?

Correct Answer is D

Explanation

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the clients is the nurse’s priority?

Correct Answer is B

Explanation

A student is caring for a patient with positive end-expiratory pressure (PEEP) at 5 cm H20. The student asks “What is the purpose of PEEP?” which of the following is an appropriate response by the nurse?

A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?

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

A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client’s care?

A nurse is caring for a client who is receiving heparin by continuous IV infusion. Which of the following medications should the nurse plan to administer in the event of an overdose?

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?

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?