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A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath.

Exhibits

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,B,D

Decreased Lung Sounds: Could indicate complications such as pneumothorax.

Heart Rate 110/min: Tachycardia may suggest a reaction to recent procedures or other underlying issues.

Subcutaneous Emphysema: Indicates possible air leakage that needs to be addressed.

Does Not Require Immediate Follow-Up:

Oxygen Saturation of 95%: Indicates acceptable oxygenation status.

Trachea Midline: Shows that there is no mediastinal shift.

Puncture Site Dry: Indicates that there is no ongoing issue at the insertion site

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Correct Answer is A

Explanation

A. Yellow sclera
Yellow sclera indicates jaundice, which could be a sign of liver dysfunction. Both isoniazid and rifampin can cause hepatotoxicity, and monitoring for jaundice is crucial to ensure the safety of the client.

B. Increasing AST level
AST level is slightly elevated but remains in the upper range of normal. Continued monitoring is necessary but may not require immediate reporting unless liver function significantly deteriorates.

C. Weight loss
Weight loss is consistent with the client’s condition and does not necessarily require immediate reporting unless it is severe or unmanageable.

D. Mantoux test result
The Mantoux test result is negative, which may be expected in the early phase of tuberculosis treatment. It should be monitored over time.

E. Increasing ALT level
ALT is slightly elevated but still within normal limits, though it's essential to continue monitoring for trends.

F. Reddish-orange urine color
Reddish-orange urine is a known side effect of rifampin and does not typically require immediate reporting

A. Restrict the client's fluid intake. B. Perform neurovascular checks with vital signs. C. Instruct the client to perform range-of-motion exercises to his lower extremities. D. Ambulate the client 1 hr following the procedure.

Correct Answer is B

Explanation

A. Fluids should not be restricted; adequate hydration is necessary to help flush the contrast dye used during the procedure out of the client's system.
B. Performing neurovascular checks with vital signs is essential to monitor for complications such as bleeding, hematoma, or compromised circulation to the extremity.
C. The client should avoid range-of-motion exercises to the lower extremities immediately following the procedure to prevent disruption of the femoral artery site.
D. The client should remain on bed rest for several hours following the procedure to reduce the risk of bleeding at the catheter insertion site.

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A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath. Exhibits The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)

Nursing Test Bank

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A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath.

Exhibits

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