Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Discomfort at the puncture site
Discomfort at the puncture site:Some discomfort at the puncture site is normal after a thoracentesis. It may be managed with pain medication as needed.
B. Serosanguineous drainage from the puncture site
Serosanguineous drainage from the puncture site:Serosanguineous drainage (a mix of clear and bloody fluid) is a common and expected finding after a thoracentesis. It is part of the normal post-procedure care.
C. Increased heart rate
Increased heart rate Increased heart rate can be indicative of a complication following a thoracentesis, such as a pneumothorax or bleeding. This requires immediate attention, and the healthcare provider should be contacted promptly for further evaluation and intervention.
D. Decreased temperature
Decreased temperature:A decreased temperature alone is not typically associated with complications following a thoracentesis. It may be related to other factors, but it is not an immediate concern compared to an increased heart rate.
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Full Explanation
A. Discomfort at the puncture site:
Some discomfort at the puncture site is normal after a thoracentesis. It may be managed with pain medication as needed.
B. Serosanguineous drainage from the puncture site:
Serosanguineous drainage (a mix of clear and bloody fluid) is a common and expected finding after a thoracentesis. It is part of the normal post-procedure care.
C. Increased heart rate
Increased heart rate can be indicative of a complication following a thoracentesis, such as a pneumothorax or bleeding. This requires immediate attention, and the healthcare provider should be contacted promptly for further evaluation and intervention.
D. Decreased temperature:
A decreased temperature alone is not typically associated with complications following a thoracentesis. It may be related to other factors, but it is not an immediate concern compared to an increased heart rate.
Similar Questions
A nurse is preparing to administer dextrose 5% in water (DW) 150 mL IV to infuse over 3 hr. The drop factor of the manual IV tubing is 10 gtt. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do not use a trailing zero.)
Full Explanation
To calculate the infusion rate for the IV solution, the nurse needs to use the formula:
Infusion rate (gtt/min) = Volume (mL) x Drop factor (gtt/mL) / Time (min)
Plugging in the given values, we get:
Infusion rate (gtt/min) = 150 mL x 10 gtt/mL / 180 min
Simplifying, we get:
Infusion rate (gtt/min) = 8.33 gtt/min
Since the answer needs to be rounded to the nearest whole number, the final answer is:
Infusion rate (gtt/min) = 8 gtt/min
A student is caring for a patient with positive end-expiratory pressure (PEEP) at 5 cm H20. The student asks “What is the purpose of PEEP?” which of the following is an appropriate response by the nurse?
A. PEEP deceases the peak respiratory pressures
PEEP decreases the peak respiratory pressures:PEEP may increase peak respiratory pressures, especially during inspiration, but its primary purpose is to prevent alveolar collapse and improve oxygenation.
B. “PEEP increases the number of breaths the patient takes on his own.”
“PEEP increases the number of breaths the patient takes on his own.”:PEEP does not increase the number of breaths the patient takes. It primarily affects the quality of ventilation by preventing alveolar collapse.
C. “PEEP augments the patient’s overall tidal volumes.”
“PEEP augments the patient’s overall tidal volumes.”: PEEP does not necessarily increase overall tidal volumes. It focuses on maintaining positive pressure at the end of expiration to prevent alveolar collapse.
D. “PEEP improves oxygenation by keeping alveoli open after exhalation.”
“PEEP improves oxygenation by keeping alveoli open after exhalation.”Positive end-expiratory pressure (PEEP) is used in mechanical ventilation to maintain positive pressure in the airways and alveoli at the end of the respiratory cycle (expiration). This helps prevent alveolar collapse and improves oxygenation by keeping the alveoli open, particularly in patients with conditions like acute respiratory distress syndrome (ARDS). PEEP is commonly used to increase functional residual capacity (FRC) and improve oxygenation.
Full Explanation
A. PEEP decreases the peak respiratory pressures:
PEEP may increase peak respiratory pressures, especially during inspiration, but its primary purpose is to prevent alveolar collapse and improve oxygenation.
B. “PEEP increases the number of breaths the patient takes on his own.”:
PEEP does not increase the number of breaths the patient takes. It primarily affects the quality of ventilation by preventing alveolar collapse.
C. “PEEP augments the patient’s overall tidal volumes.”:
PEEP does not necessarily increase overall tidal volumes. It focuses on maintaining positive pressure at the end of expiration to prevent alveolar collapse.
D. “PEEP improves oxygenation by keeping alveoli open after exhalation.”
Positive end-expiratory pressure (PEEP) is used in mechanical ventilation to maintain positive pressure in the airways and alveoli at the end of the respiratory cycle (expiration). This helps prevent alveolar collapse and improves oxygenation by keeping the alveoli open, particularly in patients with conditions like acute respiratory distress syndrome (ARDS). PEEP is commonly used to increase functional residual capacity (FRC) and improve oxygenation.
A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that a clients is at risk for metabolic acidosis?
A. A client who is taking a thiazide diuretic
A client who is taking a thiazide diuretic:Thiazide diuretics can cause loss of potassium and metabolic alkalosis, not metabolic acidosis.
B. A client who is vomiting
A client who is vomiting:Vomiting can lead to the loss of stomach acid (hydrochloric acid) and may result in metabolic alkalosis, not metabolic acidosis.
C. A client who has diarrhea
A client who has diarrhea. Diarrhea can lead to the loss of bicarbonate, an important buffer in the body that helps maintain acid-base balance. The loss of bicarbonate in diarrhea can result in an excess of acid, contributing to metabolic acidosis.
D. A client who is having an acute anxiety attack
A client who is having an acute anxiety attack:Acute anxiety is not typically associated with metabolic acidosis. It is not directly related to changes in acid-base balance.
Full Explanation
A. A client who is taking a thiazide diuretic:
Thiazide diuretics can cause loss of potassium and metabolic alkalosis, not metabolic acidosis.
B. A client who is vomiting:
Vomiting can lead to the loss of stomach acid (hydrochloric acid) and may result in metabolic alkalosis, not metabolic acidosis.
C. A client who has diarrhea.
Diarrhea can lead to the loss of bicarbonate, an important buffer in the body that helps maintain acid-base balance. The loss of bicarbonate in diarrhea can result in an excess of acid, contributing to metabolic acidosis.
D. A client who is having an acute anxiety attack:
Acute anxiety is not typically associated with metabolic acidosis. It is not directly related to changes in acid-base balance.