A client with orthopnea expresses concern about the ability to "get enough air" during a scheduled thoracentesis. On which information should the nurse's response be based?

Extra pillows can be used if needed to elevate the client's head.

The procedure is performed with the client in an upright position.

A thoracentesis is a brief procedure that has minimal discomfort.

Orthopnea is frequently caused by a client's uncontrolled anxiety.

Answer and Explanation

The Correct Answer is B

Choice A reason: Using extra pillows may help with comfort but is not the basis of the nurse's response to the concern about thoracentesis.

Choice B reason:

The correct answer is b) because during thoracentesis, the client is positioned upright, which helps ease breathing and access the pleural space.

Choice C reason: While the procedure may be brief, this response does not directly address the concern about breathing.

Choice D reason: Orthopnea can be caused by conditions other than anxiety and should be addressed appropriately.

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Correct Answer is C

Explanation

Choice A reason: Platelet count is important for clotting but does not directly address the cause of fatigue in pernicious anemia.

Choice B reason: Liver enzymes are important for liver function but are not related to pernicious anemia.

Choice C reason:

The correct answer is c) because a complete blood count (CBC) provides information about hemoglobin and hematocrit levels, which are directly impacted by pernicious anemia and can explain the fatigue.

Choice D reason: Serum electrolytes are important but do not directly address the cause of fatigue in pernicious anemia.

A. Visualize the abdominal incision. B. Notify the healthcare provider. C. Obtain sterile towels soaked in saline. D. Assure the client that such feelings occur with wound infections.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because visualizing the abdominal incision will help the nurse assess for wound dehiscence or evisceration, which requires immediate intervention.

Choice B reason: Notifying the healthcare provider is necessary but comes after assessing the wound.

Choice C reason: Obtaining sterile towels soaked in saline is important if dehiscence or evisceration is confirmed but is not the first action.

Choice D reason: Reassuring the client is important but does not address the immediate need to assess the wound.

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A client with orthopnea expresses concern about the ability to "get enough air" during a scheduled thoracentesis. On which information should the nurse's response be based?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with pernicious anemia takes supplemental folate and self-administers monthly vitamin B12 injections. The client reports feeling increasingly fatigued. Which laboratory value should the nurse review?

Correct Answer is C

Explanation

A male client who had abdominal surgery 5 days ago and was hospitalized because of a wound infection tells the nurse that he feels like his insides just spilled out when he coughed. Which action should the nurse take first?

Correct Answer is A

Explanation

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