The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)
Decreased lung sounds
Heart rate 110/min and regular
Oxygen saturation of 95%
Subcutaneous emphysema
Trachea midline
Puncture site dry
Correct Answer : A,D
A. Decreased lung sounds
A decrease in lung sounds could indicate a pneumothorax, which is a potential complication of thoracentesis. It requires prompt evaluation.
B. Heart rate 110/min and regular
A heart rate of 110/min is within a normal range, and regular rhythm is generally acceptable post-thoracentesis. It may be related to pain or anxiety but is not an immediate concern.
C. Oxygen saturation of 95%
An oxygen saturation of 95% is within an acceptable range. While maintaining adequate oxygenation is important, this finding does not suggest an immediate complication.
D. Subcutaneous emphysema
Subcutaneous emphysema involves the presence of air in the subcutaneous tissues and can indicate a communication between the pleural space and subcutaneous tissues. This requires immediate attention.
E. Trachea midline
The trachea being midline is a normal finding and does not indicate an immediate problem post-thoracentesis.
F. Puncture site dry
A dry puncture site is expected after a thoracentesis. This finding is normal and indicates appropriate wound care. It is included in the list to ensure recognition of normal post-procedure findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increased anteroposterior diameter of the chest
In emphysema, there is often hyperinflation of the lungs and destruction of the alveolar walls, leading to loss of lung elasticity. This results in increased air trapping and a characteristic "barrel chest" appearance, with an increased anteroposterior diameter.
B. Petechiae on chest:
Petechiae are small, red or purple spots caused by bleeding into the skin. They are not commonly associated with COPD and emphysema.
C. Oxygen saturation level 96%:
Oxygen saturation level of 96% is within the normal range. While oxygen saturation can be affected in COPD, the value provided is not indicative of severe hypoxemia.
D. Respiratory alkalosis:
Respiratory alkalosis is not typically associated with COPD and emphysema. In fact, respiratory acidosis is more commonly seen in these conditions due to impaired gas exchange and retention of carbon dioxide.
Correct Answer is A
Explanation
A. Cooperating:Cooperating involves working together to find a mutually beneficial solution. In this case, the charge nurse resolves the conflict by allowing both nurses to go to lunch together and taking care of their clients, ensuring that both nurses’ needs are met.
B. Avoiding:Avoiding means ignoring the conflict or withdrawing from the situation. The charge nurse is not ignoring the conflict; rather, they are actively facilitating a resolution by allowing both nurses to take lunch together.
C. Compromising:Compromising involves both parties giving up something to reach a mutually acceptable solution. While the charge nurse is helping to resolve the conflict by allowing the nurses to go to lunch, it does not imply that either nurse has made a concession in their argument, making this option less accurate.
D. Competing:
Competing involves pursuing one's own concerns at the expense of others. It is a win-lose approach to conflict resolution. The charge nurse is not demonstrating a competitive approach in this scenario, as both nurses are accommodated to go to lunch together without one person's needs being prioritized over the other.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today