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: Assessing the extremity reflexes is important for evaluating neurological function but is not the immediate priority.

Choice B reason: Logrolling to change positions is a technique used to maintain spinal alignment, but it is not the first intervention to ensure immediate safety.

Choice C reason:

The correct answer is c) because immobilizing the head in anatomical alignment is crucial to prevent further injury to the spinal cord. Proper immobilization helps stabilize the cervical spine and protects the spinal cord from additional damage.

Choice D reason: Obtaining hourly neurological assessments is important for monitoring the client's condition but comes after ensuring the cervical spine is properly immobilized.

A. Provide the client with additional oral fluids of her preference. B. Measure the client's capillary glucose reading at regular intervals. C. Encourage the client to use hard candy frequently to help relieve thirst. D. Withhold the next diuretic dose until contacting the healthcare provider.

Correct Answer is D

Explanation

Choice A reason: Providing additional oral fluids is not appropriate for SIADH and can worsen fluid retention.

Choice B reason: Measuring glucose levels is important for diabetes management but not directly related to SIADH.

Choice C reason: Using hard candy may help relieve thirst but does not address the underlying issue of fluid retention in SIADH.

Choice D reason:

The correct answer is d) because withholding diuretics and contacting the healthcare provider is necessary to manage the fluid balance in clients with SIADH.

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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

When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

Correct Answer is C

Explanation

A client with chronic syndrome of inappropriate antidiuretic hormone (SIADH) reports to the nurse of being constantly thirsty. Which action should the nurse take?

Correct Answer is D

Explanation

An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?

Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan?

A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

The nurse is administering the second unit of whole blood to an older adult client who was admitted yesterday with gastrointestinal (GI) bleeding. Which parameters should the nurse monitor that indicate fluid overload?

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

When explaining dietary guidelines to a client with acute glomerulonephritis (AGN), which instruction should the nurse include in the dietary teaching?

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