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ATI Medical Surgical Nursing, Assessment of the Respiratory System
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. A client has undergone a thoracentesis. Which assessment finding requires immediate action by the nurse? a. Decreased level of consciousness b. Tachycardia c. Increased temperature d. Sl... owed respiratory rate ANS: B An increased heart rate may indicate that the client is developing a pneumothorax or hypoxia. Although it is important to note immediately whether the client is experiencing a decreased level of consciousness, increased temperature, or a slowed respiratory rate, none of these is as indicative of a life-threatening complication as tachycardia. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Assessment) [Show More]
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