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 B
Explanation
A. Instructing the client on the use of crutches is important but not as immediate as assessing for complications.
B. Performing neurovascular checks of the extremities is the most important action to identify complications such as compartment syndrome or impaired circulation.
C. Medicating the client for pain is important but secondary to monitoring for immediate postoperative complications.
D. Directing the client to perform exercises of the ankle and toes helps prevent complications but is not as critical as performing neurovascular assessments.
Correct Answer is B
Explanation
A. Elevation of the right arm is not a primary treatment for bursitis; it is more commonly used for edema control.
B. Intermittent ice and heat helps reduce inflammation and pain associated with acute bursitis.
C. Corticosteroid therapy is a treatment option but may not be the first-line self-care strategy for acute bursitis without further evaluation by a provider.
D. Range-of-motion exercises should be avoided during acute inflammation, as it may exacerbate the condition.
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