A client with COPD is to undergo thoracentesis. What observation is of most concern after the procedure?
A) Respirations 22
B) Blood pressure 142/86 mm Hg
C) Respirations deep and regular
D) Fluid drainage from the thoracentesis site
D
Feedback:
The nurse should watch the clients for signs of fluid drainage from the thoracentesis site. Respiration rates over 25 breaths per minute or under 12 breaths per minute (when at rest) may be considered abnormal. The respiration rate may decrease due to respiratory depression when clients are receiving medications. There may be a fall in blood pressure owing to hypovolemia following large amounts of fluid being removed. The individual can breathe more easily because the pressure of the fluid, which often causes respiratory distress, has been relieved; there is no deep and regular breathing involved.
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While at recess, a child falls and hurts his arm. The school nurse is called and suspects a fractured arm. The nurse will apply a splint before transporting the child to the hospital. The nurse will ensure that:
1. The splint is applied firmly enough to prevent swelling. 2. The arm is fully extended in the splint. 3. The splint is fully padded to prevent skin damage. 4. The joints above and below the suspected fracture are immobilized.
The nurse is caring for a client who was involved in a motor vehicle accident and experienced blunt force trauma to the chest because she did not have a seat belt on and her chest impacted with the steering wheel
The nurse monitors the client for: 1. Hypovolemic shock. 2. Cardiogenic shock. 3. Septic shock. 4. Neurogenic shock.
When large amounts of ADH are released, the patient's sodium levels will be
a. increased. c. unaffected. b. decreased. d. altered inversely with potassium.
What type of posturing is she showing?
A 37-year-old woman is brought into your emergency room comatose. The paramedics say her husband found her unconscious in her home. Her past medical history consists of type 1 diabetes and she is on insulin. In the ambulance the paramedics obtained a glucose check and her sugar was 15 (normal is 70 to 105). They began a dextrose saline infusion and intubated her to protect her airway. Despite their efforts, she is posturing in the emergency room with her arms straight at her side and her jaw clenched. Her legs are also straight and her feet are plantar flexed. A) Decorticate rigidity B) Decerebrate rigidity C) Hemiplegia D) Chorea