For NCLEX Review- Uworld rationales with correct answers

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For NCLEX Review- Uworld rationales with correct answers Thoracentesis Post procedure monitoring. Assess: - Level of alertness - Lung sounds - Oxygen Sat - Resp pattern - Vital signs - Check for leakage of fluid, location of puncture site, client tolerance. - Sterile dressing after. - Check CXR to ensure absence of pneumothorax. Complication of thoracentesis: Pneumothorax, Bleeding (less common) Signs of pneumothorax Include increased respiratory rate, increased respiratory effort, respiratory distress, low oxygen saturation, and absent breath sounds on the side where the procedure was done (where the lung is collapsed). Tension pneumothorax may also develop, with tracheal shift to the unaffected side, severe respiratory distress, and cardiovascular compromise. Orthostatic vital signs involve: Measuring the client's BP and heart rate in the supine, sitting, and standing positions. Each measurement should be obtained after maintaining each position for 2 minutes. If any position change produces decreased systolic BP ≥20 mm Hg, decreased diastolic BP ≥10 mm Hg, and/or increased pulse ≥20/min from supine values, the nurse should discontinue assessment, place the client in a recumbent position, and notify the health care provide To prevent air embolism when discontinuing a central venous catheter, the nurse should perform the following interventions: Instruct to lie in a supine position. Instruct to bear down or exhale. The client should never inhale during removal of the line; inhalation will suck more air into the blood vessel via negative suction pressure. Apply an air-occlusive dressing (usually gauze with a Tegaderm dressing) to help prevent a delayed air embolism. If possible, the nurse should attempt to cover the site with the occlusive dressing while pulling out the line. Pull the line cautiously and never pull harder if there is resistance. Doing so could cause the catheter to break or become dislodged in the client's vessel. To reduce the risk of complications and injury during ET suctioning, the nurse should: - Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes. - Suction only while withdrawing the catheter from the airway. - Use strict sterile technique throughout suctioning - Limit suctioning to ≤10 seconds on each suction pass Upper Airway Obstruction: Assessment - inability to breathe or speak. - Cyanosis - Collapse - Death can occur within 4-5 mins Tracheostomy - Cuff is used to prevent aspiration and to facilitate ventilation. - Maintain cuff pressure 20-25 mm Hg - Encourage fluids to facilitate removal of secretions. - Sterile suctioning if necessary. - Frequent oral hygiene Indications for suctioning tracheostomy - Noisy respiration. - Restlessness - Increased pulse - Increased respirations. - Presence of mucus in airway Nursing Care for patients hospitalized with Acut

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