You assess C.P. 2 hours after the thoracentesis. Which information is important to report to
the physician?
a. C.P. complains of occasional chest pain when taking deep breaths.
b. C.P. has a small amount of serosanguineous drainage on the dressing.
c. C.P. has a blood pressure of 90/50 mm Hg and some increase in dyspnea.
d. C.P. states that he has some burning and stinging at the thoracentesis site.
c
Removing large quantities of fluid from the pleural space can cause fluid to shift from the
vascular spaces into the empty pleural space, causing hypotension and tachycardia. You would
need to monitor VS, lung sounds, and chest movements and immediately report any hypotension,
dyspnea, and asymmetrical chest movements. Some bleeding at the site is normal, as are continued
complaints of some pleuritic pain. Although burning and stinging typically are present during the
procedure, C.P. might have some residual discomfort. You would need to continue to assess C.P. and
monitor for the development of any problems.
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a. Balance b. Ease of stride c. Goniometer readings d. Length of stride e. Steadiness
When caring for patients, the nurse is aware that all of the following medications alter level of consciousness EXCEPT
a. benzodiazepines c. aminoglycosides b. antihypertensives d. antidiuretics
Some physicians permit clients receiving CPN to also consume a clear liquid or light diet in order to:
1. Keep the gut functioning 2. Achieve an optimal energy intake 3. Counteract the insulin that is contained in the CPN 4. Buffer the effects of the acidic CPN solution
The nurse assesses the client's IV site and determines that it has infiltrated. The nurse's best response is to:
a. call the health care provider b. immediately stop the IV infusion. c. apply a cold compress and slow the rate of infusion. d. complete an incident report.