Increased heart rate.

Discomfort at the puncture site.

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?

Decreased temperature.

Serosanguineous drainage from the puncture site.

Shortness of breath.

Chest pain.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Decreased temperature is not typically an immediate complication following a thoracentesis. It may indicate an infection, but this would develop over time rather than immediately after the procedure.
Choice B rationale
Serosanguineous drainage from the puncture site is expected after a thoracentesis and does not indicate a complication that requires immediate attention.
Choice C rationale
Shortness of breath is a serious complication that can indicate a pneumothorax or re- accumulation of fluid in the pleural space. This requires immediate attention and intervention by the healthcare provider.
Choice D rationale
Chest pain can be a sign of a complication such as a pneumothorax or infection. However, shortness of breath is a more immediate and severe symptom that requires urgent attention.

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Correct Answer is B

Explanation

Choice A rationale
Acetylcysteine is used to treat acetaminophen overdose and does not reverse the effects of heparin.
Choice B rationale
Protamine sulfate is the specific antidote for heparin and is used to reverse its anticoagulant effects.

Choice C rationale
Deferasirox is used to treat chronic iron overload and does not reverse the effects of heparin.
Choice D rationale
Vitamin K is used to reverse the effects of warfarin, not heparin.

A. Maintaining a semi-Fowler’s position as often as possible. B. Helping the client select a low-salt diet. C. Encouraging the client to drink 2 to 3 liters of water daily. D. Administering oxygen via nasal cannula at 2 L/min.

Correct Answer is C

Explanation

Choice A rationale
Maintaining a semi-Fowler’s position can help improve lung expansion and ease breathing in clients with chronic obstructive pulmonary disease (COPD). However, it does not directly address the issue of mucus congestion and difficulty in expectorating (bringing up) mucus.
While positioning can aid in overall respiratory comfort, it is not the most effective intervention for managing mucus congestion in COPD clients.
Choice B rationale
A low-salt diet is beneficial for overall health and can help manage conditions such as hypertension and heart disease. However, it does not have a direct impact on mucus congestion in clients with COPD. Dietary modifications are important for managing comorbidities, but they do not address the primary concern of mucus clearance in this scenario.
Choice C rationale
Encouraging the client to drink 2 to 3 liters of water daily is an effective intervention for managing mucus congestion in clients with COPD. Adequate hydration helps thin the mucus, making it easier to cough up and clear from the airways. This intervention directly addresses the client’s complaint of difficulty in expectorating mucus and can improve respiratory function and comfort.
Choice D rationale
Administering oxygen via nasal cannula at 2 L/min can help improve oxygenation in clients with COPD. However, it does not address the issue of mucus congestion and difficulty in expectorating mucus. While supplemental oxygen is important for managing hypoxemia, it is not the primary intervention for mucus clearance. The focus should be on interventions that help thin and mobilize mucus to alleviate the client’s symptoms.

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Increased heart rate. Discomfort at the puncture site. 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is C

Explanation

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Increased heart rate.

Discomfort at the puncture site.

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?