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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}
Explanation
- Administer furosemide: The patient has signs of pulmonary edema which needs to be managed.
- Administer ordered Epinephrine drip: Epinephrine is crucial for managing hemodynamic instability.
- Insert an indwelling urinary catheter: Monitoring urine output helps assess kidney function and fluid balance.
- Administer ordered low dose dopamine: Useful for maintaining renal perfusion and blood pressure.
- Administered 0.9% NS 500 mL bolus: Helps address hypotension and volume deficit.
- Administer ordered nitroglycerin: Not needed in this acute post-arrest phase unless specifically indicated for managing ongoing angina or heart failure symptoms.
Correct Answer is ["B","C","D","E"]
Explanation
A. Ecchymosis indicates bruising but is not a primary parameter for assessing neurovascular status.
B. Skin integrity is important to monitor for any signs of breakdown or infection.
C. Temperature helps assess for adequate blood flow and potential complications.
D. Color of the extremity indicates blood flow and can show signs of compromised circulation.
E. Sensation checks for nerve damage or impaired circulation.
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