A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid. Which of the following clinical manifestations should indicate to the nurse the client is experiencing a complication and the provider should be notified immediately?

Serosanguineous drainage from the puncture site

Discomfort at the puncture site

Increased heart rate

Decreased temperature

Answer and Explanation

The Correct Answer is C

Choice A reason: Serosanguineous drainage from the puncture site is an expected finding after a thoracentesis and does not typically indicate a complication.

Choice B reason: Discomfort at the puncture site is common following a thoracentesis and does not necessarily indicate a complication.

Choice C reason: The correct answer is c because an increased heart rate can be a sign of respiratory distress or hypovolemia, which are potential complications of a thoracentesis. This finding warrants immediate notification of the provider.

Choice D reason: A decreased temperature is not a common complication of thoracentesis and is less relevant than the other options. It is more important to monitor for signs of respiratory distress or circulatory changes.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Positioning the client supine may increase intracranial pressure. The client should be positioned with the head of the bed elevated to promote drainage and reduce pressure.

Choice B reason: The correct answer is b because changing the nasal drip pad as needed helps monitor for excessive drainage, cerebrospinal fluid leaks, and infection following pituitary gland removal.

Choice C reason: Frequent brushing of teeth should be avoided initially to prevent disruption of the surgical site and decrease the risk of infection. Gentle oral hygiene can be encouraged instead.

Choice D reason: Encouraging the client to cough every 2 hours can increase intracranial pressure and is not recommended following pituitary gland surgery. Deep breathing exercises without coughing are more appropriate.

A. Apical pulse rate different than the radial pulse rate B. Increase in heart rate by 20% when standing C. Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position D. Drop in systolic BP more than 10 mm Hg on inspiration

Correct Answer is D

Explanation

Choice A reason: An apical pulse rate different than the radial pulse rate is known as a pulse deficit, which can indicate atrial fibrillation or other cardiac arrhythmias, but it is not related to paradoxical blood pressure or constrictive pericarditis.

Choice B reason: An increase in heart rate by 20% when standing is indicative of orthostatic hypotension, not paradoxical blood pressure. This condition involves a drop in blood pressure upon standing, leading to a compensatory increase in heart rate.

Choice C reason: A drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position is another indicator of orthostatic hypotension, not paradoxical blood pressure.

Choice D reason: The correct answer is d because a drop in systolic BP of more than 10 mm Hg on inspiration, known as pulsus paradoxus, is a characteristic finding in constrictive pericarditis. This occurs due to the impaired filling of the heart during inspiration, leading to a significant drop in systolic blood pressure.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid. Which of the following clinical manifestations should indicate to the nurse the client is experiencing a complication and the provider should be notified immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has AIDS. The nurse notes that the client has multiple, widespread purplish-brown skin lesions. The nurse should suspect that the client has developed which of the following types of skin lesions?

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse identify as a risk factor for this condition?

A nurse is reinforcing teaching for a client who has COPD. Which of the following statements by the client indicates a need for further teaching?

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

A nurse is reinforcing teaching with a client who is scheduled for a thallium scan. When talking with the client about this procedure, which of the following statements should the nurse give?

A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor?

A nurse is reinforcing teaching with a client who has a new prescription for phenazopyridine. The nurse should reinforce to the client to expect which of the following while taking this medication?

A nurse at an outpatient surgery center is reinforcing discharge teaching with a client’s partner following surgical removal of a cataract. Which of the following information should the nurse include in the teaching?