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.

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Correct Answer is B

Explanation

Choice A reason: Taking a laxative the day before an IVP is a common preparation to clear the intestines for better imaging. This statement does not require additional data collection.

Choice B reason: The correct answer is b because taking metformin before an IVP can increase the risk of lactic acidosis, a serious complication. Metformin should be temporarily discontinued before and after the procedure, and the nurse should gather more information to manage the client’s diabetes safely.

Choice C reason: Fasting before an IVP is standard procedure to ensure clear imaging. This statement does not require additional data collection.

Choice D reason: Painful voiding may be related to kidney stones but is not a contraindication for an IVP. This statement does not require additional data collection.

A. "You shouldn't feel any pain since the local area is anesthetized." B. "Most clients report more discomfort from the preparation than from the procedure itself." C. "You may feel some cramping during the procedure." D. "Don't worry; you won't remember anything about the procedure due to the effects of the medication."

Correct Answer is C

Explanation

Choice A reason: Local anesthesia is not typically used for a colonoscopy. Sedation and analgesia are used to make the client comfortable, but some sensation may still be felt.

Choice B reason: While it is true that many clients find the bowel preparation uncomfortable, this statement does not address the client's concern about pain during the procedure itself.

Choice C reason: The correct answer is c because it is honest and informative. Clients may experience some cramping during a colonoscopy, but it is usually mild and can be managed with sedation and analgesia.

Choice D reason: This statement may be reassuring but is not entirely accurate. While sedation may cause some amnesia, it is important to provide realistic expectations about the procedure and potential sensations.

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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

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Explanation

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Explanation

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