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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.)

A.

Decreased lung sounds

B.

Heart rate 110/min and regular

C.

Oxygen saturation of 95%

D.

Subcutaneous emphysema

E.

Trachea midline

F.

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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Related Questions

Correct Answer is C

Explanation

A. The side-lying position is not appropriate for paracentesis because it does not allow optimal access to the abdomen and can make fluid removal more difficult.

B. The supine position is also not suitable for paracentesis, as it may not allow for proper drainage and can increase the risk of respiratory compromise, especially in clients with large volumes of ascitic fluid.

C. High-Fowler’s position is correct because it helps pool the ascitic fluid in the lower abdomen, making it easier to access and drain during the procedure. This position also helps improve breathing by relieving pressure on the diaphragm caused by the ascites.

D. The leaning forward position is not appropriate for paracentesis, as it can be uncomfortable and does not provide optimal access to the abdominal cavity for fluid removal.

Correct Answer is C

Explanation

A. Hyperglycemia typically presents with symptoms such as polyuria, polydipsia, and blurred vision, rather than these symptoms.

B. Neuropathy involves symptoms like numbness and tingling, not headache, restlessness, fatigue, and hunger.

C. Hypoglycemia presents with symptoms including headache, restlessness, fatigue, and hunger.

D. Hypokalemia presents with symptoms like muscle weakness and cramping, not the symptoms described.

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