The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?

Dullness bilaterally on percussion.

Serosanguinous drainage from the chest tube.

Diminished breath sounds in the left lower lobe.

Mediastinal shift to the right.

Answer and Explanation

The Correct Answer is D

A)   Incorrect- Dullness bilaterally on percussion is not a normal finding, but it is not an immediate concern after thoracentesis. It may indicate fluid accumulation or consolidation in both lungs, which could be related to other conditions such as pneumonia or heart failure.
B)   Incorrect- Serosanguinous drainage from the chest tube is expected after thoracentesis, as long as it is not excessive or continuous. The nurse should monitor the amount and color of the drainage and document it accordingly.
C)   Incorrect- Diminished breath sounds in the left lower lobe are also expected after thoracentesis, as the procedure removes fluid and air from the pleural space and reduces lung expansion. The nurse should auscultate the lungs before and after the procedure and compare the findings. The breath sounds should improve gradually as the lung re-expands.
D)   Correct- This is a sign of tension pneumothorax, which is a life-threatening complication of thoracentesis. Tension pneumothorax occurs when air accumulates in the pleural space and creates positive pressure that pushes the mediastinum (the heart, great vessels, and trachea) to the opposite side of the chest. This can impair venous return, cardiac output, and respiratory function. The nurse should report this finding to the healthcare provider immediately and prepare to assist with needle decompression or chest tube insertion.

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Correct Answer is C

Explanation

A) Incorrect- Furosemide is a loop diuretic used to treat conditions such as edema and hypertension. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.
B) Incorrect- Low-dose aspirin is often used for its antiplatelet effects to prevent cardiovascular events. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.
C) Correct- Allopurinol is a medication used to treat gout by reducing the production of uric acid in the body. However, allopurinol can also increase the risk of forming calcium oxalate kidney stones, which is the type of kidney stone mentioned in the client's history. Calcium oxalate stones are the most common type of kidney stone, and they are composed primarily of calcium and oxalate. In this case, the client has a history of gout and is prescribed allopurinol. The nurse should bring the client's prescription for allopurinol to the healthcare provider's attention because

it has the potential to contribute to the formation of kidney stones, which could exacerbate the client's existing condition.
D) Incorrect- Enalapril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension and heart failure. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.

A. Engage the client in regularly scheduled activities during the day. B. Offer the client frequent reassurance that he/she will be safe. C. Arrange the client's environment so the client can move about freely. D. Assign a UAP to provide the client with total personal care.

Correct Answer is C

Explanation

Clients with early-stage Alzheimer's disease may experience impaired judgment and cognitive decline, which can increase their risk for injury. Arranging the client's environment in a way that allows them to move about freely helps promote their safety and reduces the risk of accidents or falls.

Engaging the client in regularly scheduled activities during the day is a beneficial intervention as it provides structure and stimulation for the client. However, it may not directly address the risk for injury related to impaired judgment.

Offering the client frequent reassurance that they will be safe is important to provide emotional support, but it may not be sufficient in preventing physical harm or addressing the specific nursing problem of risk for injury.

Assigning a UAP (Unlicensed Assistive Personnel) to provide the client with total personal care may be helpful in assisting with activities of daily living. However, it does not directly address the risk for injury related to impaired judgment, and the nurse should have a central role in coordinating and overseeing the client's care.

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The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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