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    RN Hesi Exit Proctored ExamQuestion 54
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    RN Hesi Exit Proctored Exam

    The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?

    Explanation & Rationale

    A) Incorrect- Dullness bilaterally on percussion is not a normal finding, but it is not an immediate concern after thoracentesis. It may indicate fluid accumulation or consolidation in both lungs, which could be related to other conditions such as pneumonia or heart failure. B) Incorrect- Serosanguinous drainage from the chest tube is expected after thoracentesis, as long as it is not excessive or continuous. The nurse should monitor the amount and color of the drainage and document it accordingly. C) Incorrect- Diminished breath sounds in the left lower lobe are also expected after thoracentesis, as the procedure removes fluid and air from the pleural space and reduces lung expansion. The nurse should auscultate the lungs before and after the procedure and compare the findings. The breath sounds should improve gradually as the lung re-expands. D) Correct- This is a sign of tension pneumothorax, which is a life-threatening complication of thoracentesis. Tension pneumothorax occurs when air accumulates in the pleural space and creates positive pressure that pushes the mediastinum (the heart, great vessels, and trachea) to the opposite side of the chest. This can impair venous return, cardiac output, and respiratory function. The nurse should report this finding to the healthcare provider immediately and prepare to assist with needle decompression or chest tube insertion.

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