A nurse is caring for a 75-year-old male patient 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)
Diminished lung sounds
Heart rate 110/min and regular
Oxygen saturation of 95%
Subcutaneous emphysema
Trachea midline
Puncture site dry
Correct Answer : A,B,D
Choice A: Diminished Lung Sounds
Reason: Diminished lung sounds can indicate several serious conditions that require immediate follow-up. In the context of a patient who has just undergone a thoracentesis, diminished lung sounds could suggest a pneumothorax (collapsed lung), which is a known complication of the procedure. Pneumothorax occurs when air leaks into the space between the lung and chest wall, causing the lung to collapse. This condition can lead to severe respiratory distress and requires prompt intervention, such as the insertion of a chest tube to re-expand the lung. Additionally, diminished lung sounds could indicate reaccumulation of pleural fluid, which would necessitate further drainage or other interventions.
Choice B: Heart Rate 110/min and Regular
Reason: A heart rate of 110 beats per minute (bpm) is considered tachycardia, which is above the normal resting heart rate range of 60-100 bpm for adults. In elderly patients, a heart rate above 100 bpm can be particularly concerning as it may indicate underlying issues such as hypoxemia (low blood oxygen levels), infection, or cardiac problems. Tachycardia following a thoracentesis could be a sign of respiratory distress or pain, both of which require immediate assessment and management. It is crucial to determine the underlying cause of the elevated heart rate to prevent further complications.
Choice C: Oxygen Saturation of 95%
Reason: An oxygen saturation level of 95% is generally considered within the normal range (95-100%) for healthy individuals. However, in the context of a patient with a history of lung cancer, pleural effusions, and recent thoracentesis, this value might be borderline. While it does not require immediate follow-up, it should be monitored closely. Any further drop in oxygen saturation would necessitate intervention, such as supplemental oxygen or further diagnostic testing to determine the cause of the hypoxemia.
Choice D: Subcutaneous Emphysema
Reason: Subcutaneous emphysema is the presence of air in the subcutaneous tissue, which can occur as a complication of thoracentesis. It is often identified by a characteristic crackling sensation felt under the skin. This condition can indicate a more serious underlying issue, such as a pneumothorax or tracheal injury, both of which require immediate medical attention. Management of subcutaneous emphysema involves addressing the underlying cause, which may include the insertion of a chest tube or other interventions to remove the trapped air and prevent further complications.
Choice E: Trachea Midline
Reason: The trachea being midline is a normal finding and does not require immediate follow-up. A deviation of the trachea to one side can indicate a tension pneumothorax or significant pleural effusion, both of which are medical emergencies. However, in this case, the trachea is midline, suggesting that there is no immediate concern related to tracheal deviation.
Choice F: Puncture Site Dry
Reason: A dry puncture site is a normal finding post-thoracentesis and does not require immediate follow-up. It indicates that there is no active bleeding or significant fluid leakage from the site. The dressing should be monitored for any signs of infection or excessive drainage, but a dry puncture site is generally a positive sign of proper healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","F"]
Explanation
Choice A: Potassium Level
Reason: Monitoring potassium levels is crucial in clients with bulimia nervosa due to the risk of hypokalemia (low potassium levels), which can result from frequent vomiting and laxative abuse. Hypokalemia can lead to serious complications, including cardiac arrhythmias. In this case, the client’s potassium level improved from 3.2 mEq/L (below the normal range of 3.5 to 5 mEq/L) on June 1 to 3.7 mEq/L (within the normal range) on June 15. This improvement indicates a positive response to treatment, as it suggests that the client is experiencing fewer episodes of vomiting or laxative abuse, leading to better electrolyte balance.
Choice B: ECG Report
Reason: While the ECG report is important for assessing cardiac health, it is not a direct indicator of therapeutic response to bulimia nervosa treatment. The presence of premature ventricular contractions (PVCs) on the ECG can be related to electrolyte imbalances, particularly hypokalemia. However, the ECG itself does not provide information about the client’s behaviors or coping mechanisms, which are more directly related to the treatment of bulimia
nervosa. Therefore, while the ECG report is useful for monitoring cardiac health, it is not one of the primary indicators of therapeutic response in this context.
Choice C: BUN Level
Reason: Blood Urea Nitrogen (BUN) levels can indicate kidney function and hydration status. Elevated BUN levels, as seen in this client (28 mg/dL on June 1 and 26 mg/dL on June 15, with a normal range of 10 to 20 mg/dL), may suggest dehydration or impaired kidney function. However, BUN levels are not specific indicators of therapeutic
response to bulimia nervosa treatment. They do not directly reflect changes in the client’s eating behaviors, purging habits, or coping skills. Therefore, while monitoring BUN levels is important for overall health, it is not a primary indicator of therapeutic response in this case.
Choice D: Laxative Usage
Reason: Reducing or eliminating laxative usage is a significant indicator of therapeutic response in clients with bulimia nervosa. Laxative abuse is a common purging behavior in bulimia nervosa, and its reduction indicates progress in treatment. The client’s report of laxative usage provides direct insight into their purging behaviors. A
decrease in laxative use suggests that the client is gaining better control over their eating disorder and is adhering to the treatment plan. This behavioral change is a critical component of recovery and indicates a positive therapeutic response.
Choice E: Overeating Cycle/Purging
Reason: Assessing changes in the client’s overeating and purging cycle is essential for evaluating therapeutic response. Bulimia nervosa is characterized by cycles of binge eating followed by purging behaviors such as vomiting or laxative abuse. A reduction in the frequency or severity of these cycles indicates that the client is responding well to treatment. The client’s self-reported behaviors regarding overeating and purging provide valuable information about their progress. A decrease in these behaviors suggests that the client is developing healthier eating patterns and coping mechanisms, which are key goals of treatment.
Choice F: Coping Skills
Reason: Developing effective coping skills is a crucial aspect of treatment for bulimia nervosa. Clients often use disordered eating behaviors as a way to cope with emotional distress. By learning and implementing healthier coping strategies, clients can reduce their reliance on harmful behaviors such as binge eating and purging. Assessing the client’s coping skills involves evaluating their ability to manage stress, emotions, and triggers in a healthy manner. Improvement in coping skills indicates that the client is making progress in their recovery and is better equipped to handle challenges without resorting to disordered eating behaviors.
Correct Answer is B
Explanation
Choice A reason: Increasing age is a non-modifiable risk factor for cardiovascular disease. As people age, their risk of developing cardiovascular conditions naturally increases due to changes in the heart and blood vessels. However, age cannot be altered or controlled, making it a non-modifiable factor.
Choice B reason: Cigarette smoking is a significant modifiable risk factor for cardiovascular disease. Smoking damages the lining of the arteries, leading to atherosclerosis (narrowing and hardening of the arteries), which can result in heart attacks and strokes. Quitting smoking can significantly reduce the risk of cardiovascular disease, making it a key focus in prevention programs.
Choice C reason: Family history of cardiac disease is another non-modifiable risk factor. Genetics play a crucial role in the predisposition to cardiovascular diseases. If a close family member has had heart disease, the risk is higher. While this factor cannot be changed, awareness can lead to more proactive management of other modifiable risks.
Choice D reason: Diagnosis of diabetes mellitus is a complex risk factor. While having diabetes itself is not modifiable, the management of diabetes through lifestyle changes, medication, and monitoring can significantly reduce the risk of cardiovascular complications. Proper control of blood glucose levels, diet, and exercise are crucial in mitigating this risk.
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