A client with exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for a thoracentesis. Which nursing intervention would be appropriate for client safety?

Administering a cough suppressant as needed.

Assisting the client to a prone position.

Obtaining arterial blood gas values immediately after the procedure.

Applying oxygen via nasal cannula.

Answer and Explanation

The Correct Answer is D

Choice A reason: Cough suppressants may reduce discomfort but don’t address hypoxia risk during thoracentesis in COPD exacerbation. Oxygen application ensures safety, making this incorrect, as it doesn’t prioritize respiratory support needed for the client undergoing a procedure affecting lung function.

Choice B reason: A prone position is unsafe for thoracentesis, which requires an upright or side-lying position to access pleural fluid. Oxygen supports breathing, making this incorrect, as it risks procedural complications compared to ensuring oxygenation for the COPD client’s safety.

Choice C reason: Arterial blood gases post-procedure assess respiratory status but aren’t the primary safety intervention during thoracentesis. Oxygen prevents hypoxia, making this secondary and incorrect compared to the immediate need for respiratory support in the COPD client undergoing the procedure.

Choice D reason: Applying oxygen via nasal cannula ensures adequate oxygenation during thoracentesis, critical for a COPD client with exacerbation prone to hypoxia. This aligns with procedural safety protocols, making it the correct intervention to maintain client safety during the pleural fluid removal.

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Correct Answer is ["A","B","E"]

Explanation

Choice A reason: Avoiding submersion until the incision heals prevents infection in a new pacemaker site. This aligns with post-implant care, making it a correct instruction the nurse would include to ensure proper healing and device safety for the client.

Choice B reason: Reporting pulse rates below pacemaker settings indicates potential device failure, requiring prompt evaluation. This aligns with pacemaker monitoring, making it a correct instruction the nurse would teach the client to ensure device function and cardiac stability.

Choice C reason: Applying pressure over the generator doesn’t address weakness and may harm the device. Reporting low pulse rates is correct, making this incorrect, as it’s not a valid instruction for the nurse to include in pacemaker teaching.

Choice D reason: Pacemakers aren’t turned off for MRI; MRI-compatible devices or alternatives are used. Arm movement restriction is correct, making this incorrect, as it’s inaccurate compared to the nurse’s proper instructions for pacemaker care and MRI safety.

Choice E reason: Avoiding arm lifting above the shoulder for 8 weeks prevents lead dislodgement in a new pacemaker. This aligns with post-implant restrictions, making it a correct instruction the nurse would include to protect the device’s integrity.

A. Serum glucose 120 mg/dL. B. White cell count 15,000/mm³. C. Skin is warm, dry, and flushed. D. Bleeding noted around venipuncture site.

Correct Answer is D

Explanation

Choice A reason: Serum glucose of 120 mg/dL is normal and not concerning in septic shock, where coagulopathy is critical. Bleeding at the venipuncture site suggests DIC, making this incorrect, as it’s less urgent than the nurse’s priority of addressing potential bleeding complications.

Choice B reason: A white cell count of 15,000/mm³ is expected in septic shock due to infection. Bleeding indicates coagulopathy, a severe complication, making this incorrect, as it’s a typical finding compared to the nurse’s concern for life-threatening bleeding in the client.

Choice C reason: Warm, dry, flushed skin is common in early septic shock’s hyperdynamic phase. Bleeding suggests disseminated intravascular coagulation, making this incorrect, as it’s less concerning than the nurse’s priority of addressing a potential coagulopathy in the septic shock client.

Choice D reason: Bleeding around the venipuncture site in septic shock suggests disseminated intravascular coagulation, a life-threatening complication. This aligns with critical care priorities, making it the correct observation most concerning to the nurse, requiring immediate intervention to address coagulopathy.

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A client with exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for a thoracentesis. Which nursing intervention would be appropriate for client safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse teaches a client with a new permanent pacemaker. Which instructions would the nurse include in this client’s teaching? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

The critical care nurse cares for a client diagnosed with septic shock. Which observation MOST concerns the nurse?

Correct Answer is D

Explanation

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