The nurse cares for a patient who has just had a thoracentesis. ...

[mrsjacobs44]

The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
 
  a. Oxygen saturation is 88.
  b. Blood pressure is 145/90 mm Hg.
  c. Respiratory rate is 22 breaths/minute when lying flat.
  d. Pain level is 5 (on 0 to 10 scale) with a deep breath.

Question 2

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
 
  a. Chest x-ray via stretcher
  b. Blood cultures from two sites
  c. Ciprofloxacin (Cipro) 400 mg IV
  d. Acetaminophen (Tylenol) rectal suppository

[djofnc]

Answer to Question 1

ANS: A
Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 88 indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.

Answer to Question 2

ANS: B
Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.