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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
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.
Correct Answer is A
Explanation
A. “I have not received any of my medications today.”
The statement "I have not received any of my medications today" requires follow-up from the nurse because it indicates a potential issue with the client's medication administration. It's important to ensure that the client receives the prescribed medications in a timely manner.
B. “Do you know when I will be going home?”
This is a question about the discharge plan and does not indicate an immediate issue that requires follow-up.
C. “I do not know how to make the remote control work.”
While it's a statement about the client's understanding of the remote control, it is not an urgent matter that requires immediate attention.
D. “My dressing was changed earlier this morning.”
This statement indicates that a care task (dressing change) has been completed and does not suggest a problem that requires urgent follow-up.
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