Respiratory Question #29

Question

The nurse is caring for a client following a thoracentesis. The nurse contacts the health care provider because of which finding?

Answers

  1. Diminished breath sounds on the affected side.
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  2. Crackles remain unchanged since previous assessment.
    • Rationale:
  3. Symmetrical chest expansion.
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  4. Respiratory rate of 26 breaths per minute.
    • Rationale:

Overview

Explanation

Following a thoracentesis, the nurse will monitor for signs of pneumothorax which may be a complication of the procedure. Diminished breath sounds may be an early sign. Other signs may include dyspnea, retractions, increased respiratory rate, and cyanosis. Crackles, though not normal, remained unchanged over previous assessment, while diminished breath sounds represent new findings consistent with complications following a thoracentesis. Symmetrical breath sounds are normal findings. While a respiratory rate is 24 breaths/min, and abnormal, it does not signify complications alone. Respiratory rate is generally between 12-18 breaths per minute and varies with age, gender, and condition. No other information about the respiratory assessment indicated dyspnea, or other complications while breathing. Diminished breath sounds on auscultation provides a better assessment of possible complications that respiratory rate alone.

Learning Outcomes

Test Taking Tip

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