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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Metabolic alkalosis with full compensation:
This is not the correct interpretation. Metabolic alkalosis is characterized by an elevated pH and elevated bicarbonate (HCO3-) levels. In this case, the pH is low (acidosis), and the bicarbonate level is within the normal range, suggesting a respiratory issue rather than a metabolic one.
B. Respiratory alkalosis with partial compensation:
This is not the correct interpretation. Respiratory alkalosis is characterized by an elevated pH and decreased PaCO2. In this case, the pH is low (acidosis), and the PaCO2 is elevated, indicating respiratory acidosis rather than alkalosis.
C. Metabolic acidosis with partial compensation:
This is not the correct interpretation. Metabolic acidosis is characterized by a low pH and decreased bicarbonate (HCO3-) levels. In this case, the bicarbonate level is within the normal range, and the elevated PaCO2 suggests a respiratory issue, not metabolic acidosis.
D. Respiratory acidosis with no compensation:
This is the correct interpretation. Respiratory acidosis is characterized by a low pH and an elevated PaCO2. The normal bicarbonate level indicates that compensatory mechanisms (such as the kidneys increasing bicarbonate reabsorption) have not fully corrected the pH imbalance, leading to respiratory acidosis with no compensation.
Correct Answer is C
Explanation
A. Right Circumstances:
This involves ensuring that the tasks being delegated are appropriate for the circumstances and consistent with the plan of care. The nurse should consider factors such as the client's condition, the complexity of the task, and the stability of the client's health status.
B. Right Communication:
Effective communication is crucial in delegation. This includes clear and concise instructions, expectations, and a feedback loop. The nurse should ensure that communication is understood and acknowledged by both parties involved in the delegation.
C. Right Supervision:
Right Supervision involves providing guidance, direction, and feedback to those to whom tasks have been delegated. The nurse is responsible for overseeing and ensuring that the tasks are performed appropriately, meeting the required standards of care. This includes ongoing monitoring and assessment of delegated tasks.
D. Right Person:
The right person involves selecting the appropriate individual for the task based on their competence, knowledge, and skills. The nurse must assess the competency of the person being delegated to and ensure that they have the necessary qualifications to perform the assigned task
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