A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse?

Reference Range:

Arterial Blood Gas (ABG) pH [7.35 to 7.45]

PaCO, [35 to 45 mm Hg]

HCO 21 to 28 mEq/L (21 to 28 mmol/L)]

PaO2 [80 to 100 mm Hg]

The client's chest x-ray Indicates decreased pleural effusion.

The client's arterial blood gas result is a pH 7.35, PaCO, 35 mm Hg, HCO,-26 mEq (26 mmol/L), PaO, 85 mm Hg.

The client has asymmetrical chest wall expansion.

The client reports pain at the insertion site.

Answer and Explanation

The Correct Answer is C

A.   A decreased pleural effusion on a chest x-ray is generally a positive outcome following a thoracentesis. It indicates that the procedure was successful in removing the excess fluid. This finding does not warrant immediate intervention and is expected after the procedure.
B.   The pH of 7.35 indicates acidosis (normal range is 7.35 to 7.45). The PaCO₂ is on the lower end of normal, suggesting that if there is an acid-base imbalance, it might be metabolic or mixed. The HCO₃⁻ is within normal limits, indicating no metabolic component. The PaO₂ is slightly below the normal range (80-100 mm Hg), which could be a concern but is not critically low.
C.   Asymmetrical chest wall expansion can indicate a complication such as pneumothorax (air in the pleural space), which could occur as a complication of thoracentesis. This finding warrants immediate intervention because it may signify a serious issue that requires prompt attention, such as the need for a chest tube or further evaluation.
D.   Pain at the insertion site is expected following a thoracentesis and is generally not an urgent concern unless it is severe or associated with other symptoms like fever, difficulty breathing, or signs of infection. This type of pain is usually managed with analgesics and does not typically require immediate intervention unless accompanied by more serious symptoms.

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 {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

"I can stop taking the phenytoin If I go for a while and don't have a seizure." This statement indicates a lack of understanding. Anti-seizure medications are typically lifelong and should not be stopped without medical advice.

"Having a medic alert bracelet might be a good idea, but it is up to me to decide if I want it or not." This statement also shows a lack of understanding. A medic alert bracelet is crucial for individuals with seizures, as it provides essential information to emergency responders in case of an emergency.

"I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row." This statement demonstrates a lack of understanding. Any seizure should be reported to a healthcare provider, as it could indicate changes in seizure control.

“There are really no lifestyle changes that I can do that will affect my risk for having another seizure." This statement indicates a lack of understanding. Certain lifestyle factors, such as sleep deprivation, stress, and alcohol consumption, can trigger seizures.

"I may never know why! started having seizures." This statement indicates understanding. While the cause of seizures is often unknown, it's important for the client to acknowledge this possibility.

A. Ask the client to rate her pain on a scale from 0 to 10. B. Teach the client to keep the leg elevated C. Treat with ice then apply an elastic bandage wrap. D. Check the leg for warmth and erythema.

Correct Answer is D

Explanation

A. While pain assessment is important, it's not the priority in this situation. Pain can be present in various conditions, and it doesn't necessarily indicate DVT.
B. Elevating the leg can help reduce swelling but is not the initial action. The nurse needs to rule out a serious condition like DVT first.
C. Applying ice and an elastic bandage might be appropriate for some types of swelling but is not the correct initial action for a sudden, unilateral leg swelling.
D. The client presents with sudden, unilateral leg swelling, which is a red flag for deep vein thrombosis (DVT). DVT is a serious condition that can lead to pulmonary embolism. Therefore, the nurse's priority is to assess for signs of inflammation, which are warmth and erythema.

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

A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse? Reference Range: Arterial Blood Gas (ABG) pH [7.35 to 7.45] PaCO, [35 to 45 mm Hg] HCO 21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse provides education about seizures to the client and asks the client to explain what he understands about his condition. For each statement click to specify if the client demonstrates an understanding or no understanding. Each row must have one option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Correct Answer is D

Explanation

The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?

While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

Which nursing action is most helpful in promoting circulation in a client with chronic venous insufficiency?

Exhibits The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?

The nurse is collecting a urine specimen for a client with symptoms related to urethritis. Which collection method should the nurse implement?

A client with chronic obstructive pulmonary disease (COPD) has become extremely dyspneic. After determining that the client is in high- Fowler's position and is receiving oxygen via nasal cannula at 2 liters/minute, which immediate action should the nurse take?