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 A
Explanation
A. Teaching a client insulin injection technique.
Licensed practical nurses (LPNs) are trained to provide direct patient care, including the administration of medications and patient education. Teaching a client insulin injection technique falls within the scope of practice for an LPN.
B. Evaluating changes to a client’s pressure ulcer:
Assessing and evaluating changes in a client's condition, including pressure ulcers, involves clinical judgment and interpretation of findings, tasks typically performed by an RN.
C. Admission assessment of a new client:
Conducting comprehensive assessments, especially for new admissions, requires a higher level of nursing assessment skills and is generally within the scope of practice for an RN.
D. Scheduling a diagnostic study for a client:
The task of scheduling diagnostic studies involves organizational and administrative skills. RNs often handle coordination of care, including scheduling, as part of their responsibilities.
Correct Answer is D
Explanation
A. Pain in the affected leg could indicate worsening of cellulitis or a potential complication like deep vein thrombosis (DVT), but there is no immediate indication of a life-threatening condition. This client should be assessed, but may not be the top priority unless other signs of complications are present.
B. A serum calcium level of 10 mg/dL is within the normal range (8.5 to 10.5 mg/dL). A headache, while concerning, is not immediately life-threatening unless there are additional symptoms suggesting something more severe.
C.Reddish brown urine suggests hematuria, a symptom of glomerulonephritis. This could indicate ongoing kidney issues, but unless there are signs of severe kidney failure or systemic infection, this might not be the most urgent case.
D. A blood glucose level of 68 mg/dL is low and can lead to hypoglycemia, which can be immediately life-threatening if it progresses to severe hypoglycemia. Symptoms of hypoglycemia include confusion, dizziness, sweating, and can escalate to seizures or unconsciousness if not promptly treated.
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