A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?
Discomfort at the puncture site
Serosanguineous drainage from the puncture site
Increased heart rate
Decreased temperature
The Correct Answer is C
A. Discomfort at the puncture site:
Some discomfort at the puncture site is normal after a thoracentesis. It may be managed with pain medication as needed.
B. Serosanguineous drainage from the puncture site:
Serosanguineous drainage (a mix of clear and bloody fluid) is a common and expected finding after a thoracentesis. It is part of the normal post-procedure care.
C. Increased heart rate
Increased heart rate can be indicative of a complication following a thoracentesis, such as a pneumothorax or bleeding. This requires immediate attention, and the healthcare provider should be contacted promptly for further evaluation and intervention.
D. Decreased temperature:
A decreased temperature alone is not typically associated with complications following a thoracentesis. It may be related to other factors, but it is not an immediate concern compared to an increased heart rate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assessing a client who experiences unilateral calf pain when ambulating.
Unilateral calf pain in a client who is ambulating can be indicative of a potential deep vein thrombosis (DVT), which is a serious condition that requires prompt assessment and intervention. DVTs are a risk after surgery, and early detection is crucial to prevent complications such as a pulmonary embolism. Assessing the client experiencing calf pain is the priority to determine the cause and initiate appropriate interventions.
B. Reassuring the partner of a client who sustained a closed head injury:
While providing support and reassurance to family members is important, it is not as urgent as assessing a client with potential signs of a DVT.
C. Taking a telephone prescription about a client who is to be transferred from PACU:
While obtaining and implementing orders in a timely manner is important, assessing and addressing a potential DVT takes precedence due to the immediate risk to the client's well-being.
D. Reinforcing a client’s dressing for the surgical site of an above-the-knee amputation:
Dressing reinforcement is important for wound care, but it is not as urgently needed as assessing a client with possible signs of a DVT. The assessment of calf pain takes priority.
Correct Answer is B
Explanation
A. Integrity of the dressing:
Dressing integrity is important for wound care, but it is not the top priority when considering the client's immediate postoperative needs.
B. Need for suctioning
Maintaining a patent airway is crucial after a total laryngectomy. The absence of a larynx removes the client's ability to breathe through the nose and mouth, so maintaining a clear airway is a top priority. Suctioning may be necessary to remove secretions and maintain airway patency.
C. Patency of the intravenous line:
Intravenous line patency is important for fluid and medication administration, but it is not the priority when compared to maintaining a clear airway.
D. Level of pain:
Pain management is important for the client's comfort, but it is not the immediate priority compared to ensuring a patent airway following a total laryngectomy.
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