Exhibits

A nurse is collecting data from a client following a thoracentesis. The nurse should notify the provider for which of the following findings? (Click on the "Exhibit" button for additional information about the client There are three tabs that contain separate categories of data.)

Respiratory rate

Blood pressure

Hematocrit

PCO2

Answer and Explanation

The Correct Answer is A

Choice A. Respiratory rate
Reason: After thoracentesis, it's crucial to monitor the patient's respiratory rate. An increased respiratory rate could indicate respiratory distress. In this case, the respiratory rate is 26/min, which is higher than the normal range (12-20 breaths per minute for an adult at rest). Therefore, the nurse should notify the provider about this finding.

Choice B. Blood pressure
Reason: The blood pressure of the patient is 110/76 mm Hg, which falls within the normal range (90/60 mm Hg to 120/80 mm Hg). Therefore, there is no need for the nurse to notify the provider about the patient's blood pressure.

Choice C. Hematocrit
Reason: The hematocrit level is 43%, which is within the normal range (38.8% to 50.0% for males, and 34.9% to 44.5% for females). Therefore, there is no need for the nurse to notify the provider about the patient's hematocrit level².

Choice D. PCO2
Reason: The PCO2 level is 37 mm Hg, which is within the normal range (35 to 45 mm Hg). Therefore, there is no need for the nurse to notify the provider about the patient's PCO2 level.

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Correct Answer is D

Explanation

The correct answer is: d. Wear an N95 mask when in the client’s room.

Choice A: Place the client in a negative air pressure room

Reason: Negative air pressure rooms are typically used for airborne infections like tuberculosis, which require airborne precautions. Pertussis, however, is spread through respiratory droplets, not airborne particles. Therefore, placing a pertussis patient in a negative air pressure room is unnecessary and not recommended.

Choice B: Wear a simple face mask when caring for the client

Reason: While a simple face mask can provide some protection against respiratory droplets, it is not sufficient for healthcare workers caring for patients with pertussis. Pertussis is highly contagious, and healthcare workers need more effective protection to prevent inhalation of infectious droplets.

Choice C: Wear a gown when caring for the client

Reason: Wearing a gown can help protect healthcare workers from contact with respiratory secretions, but it is not the primary protective measure needed for pertussis. The main mode of transmission is through respiratory droplets, so respiratory protection is more critical.

Choice D: Wear an N95 mask when in the client’s room

Reason: An N95 mask provides a higher level of respiratory protection compared to a simple face mask. It is designed to filter out at least 95% of airborne particles, including large respiratory droplets that can carry the pertussis bacteria. This makes it the most appropriate choice for protecting healthcare workers from pertussis infection when caring for an infected patient.

A. Sore throat B. Presence of gag reflex C. Blood pressure 110/78 mm Hg D. Facial edema

Correct Answer is D

Explanation

Choice A reason: A sore throat is a common and expected finding after a bronchoscopy due to the irritation caused by the procedure.

Choice B reason: The presence of a gag reflex is a normal finding and indicates that the reflex has returned after the procedure.

Choice C reason: A blood pressure of 110/78 mm Hg is within the normal range and does not need to be reported.

Choice D reason: Facial edema is not a typical finding after a bronchoscopy and could indicate an allergic reaction or other complication.

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Exhibits A nurse is collecting data from a client following a thoracentesis. The nurse should notify the provider for which of the following findings? (Click on the "Exhibit" button for additional information about the client There are three tabs that contain separate categories of data.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with an assistive personnel (AP) about a client who has pertussis. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is collecting data from a client who had a bronchoscopy. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

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Exhibits

A nurse is collecting data from a client following a thoracentesis. The nurse should notify the provider for which of the following findings? (Click on the "Exhibit" button for additional information about the client There are three tabs that contain separate categories of data.)