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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Coronary arteries decrease in diameter leading to insufficient blood, oxygen, and nutrients reaching the heart muscle. This is correct because atherosclerosis, which is the buildup of plaque in the coronary arteries, causes the arteries to narrow. This narrowing reduces blood flow to the heart muscle, leading to ischemia and the manifestations of coronary artery disease, such as angina and myocardial infarction.
Choice B rationale
Manifestations occur due to dilation of coronary arteries with increased blood flow causing increased pressure. This is incorrect because the primary issue in coronary artery disease is the narrowing of the arteries, not their dilation. Increased blood flow and pressure are not typical causes of the manifestations of coronary artery disease.
Choice C rationale
Coronary arteries become more elastic causing the arteries to stretch as individuals age causing the heart not to receive enough oxygen. This is incorrect because the problem in coronary artery disease is not increased elasticity but rather the loss of elasticity and the buildup of plaque that narrows the arteries. As people age, the arteries tend to become less elastic, not more.
Choice D rationale
The heart and the coronary arteries weaken, leading to poor perfusion and resulting in angina. This is incorrect because the primary issue in coronary artery disease is the narrowing of the coronary arteries due to plaque buildup, not the weakening of the heart and arteries. While poor perfusion does result in angina, it is due to the narrowed arteries rather than weakened structures.
Correct Answer is A
Explanation
Choice A rationale
Giving the child acetaminophen for discomfort is appropriate as it helps manage pain without interfering with the healing process.
Choice B rationale
Keeping the child home for 1 week is not necessary unless there are specific complications or instructions from the healthcare provider.
Choice C rationale
Assisting the child to take a tub bath for the first 3 days is not recommended as it may increase the risk of infection at the catheter insertion site.
Choice D rationale
Offering the child clear liquids for the first 24 hours is not necessary unless there are specific dietary restrictions from the healthcare provider.
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