A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath.
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,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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Nasal congestion is not a primary sign of autonomic dysreflexia, though it can be a symptom of other conditions.
B. A severe headache can be a symptom of autonomic dysreflexia but is not the sole indicator of the condition.
C. Elevated blood pressure can be a result of autonomic dysreflexia but is not necessarily an indication of risk without other symptoms.
D. A distended bladder is a common trigger for autonomic dysreflexia in clients with a spinal cord injury at or above T-6, making it a key indicator for monitoring.
Correct Answer is B
Explanation
A. Coffee has not been shown to significantly increase the risk of gout attacks and may even have a protective effect due to its antioxidant properties.
B. Alcohol, especially beer and spirits, can trigger gout attacks by increasing the level of uric acid in the blood. Alcohol consumption should be limited or avoided to reduce the risk of gout flare-ups.
C. Milk and other low-fat dairy products are actually recommended for people with gout, as they may help lower uric acid levels.
D. Orange juice, while high in vitamin C, does contain fructose, which can increase uric acid production. However, it is not as significant a trigger as alcohol. Moderation is key.
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