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","E"]
Explanation
A. Place a pillow under the client's head.
Rationale: This action helps to prevent head injury during a seizure by cushioning the head.
B. Place the client into a supine position.
Rationale: This is incorrect because it can increase the risk of aspiration. The client should be placed in a side-lying position to allow the mouth to drain and prevent aspiration.
C. Apply restraints.
Rationale: This is incorrect as restraints can cause injury to the client during a seizure. The nurse should instead ensure the environment is safe and free from objects that could harm the client.
D. Insert a bite stick into the client's mouth.
Rationale: This is incorrect because inserting any object into the mouth during a seizure can cause dental injury or aspiration. The jaw should not be forced open.
E. Loosen restrictive clothing.
Rationale: This action helps to prevent injury and allows for easier breathing during a seizure. It also prevents any constriction that could occur due to muscle contractions.
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.
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