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.

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

Thoracentesis is a brief procedure that has minimal discomfort.

Answer and Explanation

The Correct Answer is B

A. Extra pillows can be used if needed to elevate the client's head: While pillows may help relieve mild respiratory discomfort, they may not provide sufficient support for someone with orthopnea, especially during a procedure. Relying on pillows alone does not address the optimal positioning required during thoracentesis.

B. The procedure is performed with the client in an upright position: Thoracentesis is typically done with the client sitting upright and leaning slightly forward, which enhances lung expansion and helps alleviate orthopnea by reducing diaphragmatic pressure. This positioning not only facilitates needle access to the pleural space but also improves the client’s respiratory comfort.

C. Orthopnea is frequently caused by a client's uncontrolled anxiety: Orthopnea is a physiological symptom, usually related to heart or lung conditions, not psychological factors. Suggesting it's due to anxiety may invalidate the client’s experience and delay appropriate supportive interventions.

D. Thoracentesis is a brief procedure that has minimal discomfort: While generally true, this statement overlooks the client’s current concern about breathing difficulty. Focusing solely on procedural duration or discomfort doesn't address the anxiety and physical limitations imposed by orthopnea.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Radiating, sharp pain in right shoulder: This pain is a common symptom of gallbladder inflammation or biliary colic due to referred pain from diaphragmatic irritation. While it should be documented and managed for comfort, it is not immediately life-threatening or indicative of worsening complications.

B. Clay colored stool: Pale or clay-colored stools occur when bile flow into the intestines is obstructed, leading to a lack of stercobilin, the pigment responsible for stool color. This finding confirms bile duct obstruction but is expected in the context of cholelithiasis with jaundice and doesn’t require urgent intervention.

C. Bile stained emesis: Vomiting bile indicates upper gastrointestinal involvement and is often associated with prolonged nausea due to gallbladder or liver pathology. While uncomfortable and noteworthy, it is not as alarming as signs of acute abdominal complications.

D. Distended, hard, and rigid abdomen: This finding suggests peritonitis or a perforated viscus, which are surgical emergencies. A rigid abdomen indicates guarding and possible internal inflammation or infection, requiring immediate medical evaluation and intervention to prevent rapid deterioration.

A. Increase frequency of BP assessments. B. Encourage the client to breathe deeply. C. Check the abdominal surgical dressing. D. Review the client's baseline BP trends.

Correct Answer is C

Explanation

A. Increase frequency of BP assessments: More frequent monitoring is important when vital signs begin to trend downward, but it does not address the potential cause of the drop in blood pressure. Without an intervention to identify the underlying issue, further decline could be missed or untreated.

B. Encourage the client to breathe deeply: Deep breathing is useful in preventing postoperative atelectasis, but it is unrelated to a drop in blood pressure. This action does not target the most immediate concern of potential postoperative bleeding or hypovolemia.

C. Check the abdominal surgical dressing: A significant drop in blood pressure shortly after abdominal surgery may indicate internal or external bleeding. Inspecting the surgical site for signs of haemorrhage such as visible drainage, distention, or saturation of the dressing helps identify early postoperative complications and guides rapid intervention.

D. Review the client's baseline BP trends: While understanding the client’s normal blood pressure is helpful, it does not substitute for an immediate physical assessment when acute changes are occurring. Delaying direct observation to review history could allow a preventable complication to worsen.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer is D

Explanation

One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

Correct Answer is C

Explanation

A client with eczema is applying 10% urea cream onto the affected skin areas. Which finding reflects the expected therapeutic response?

The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). When providing teaching on lowering blood glucose levels and increasing serum high-density lipoprotein (HDL) levels, which instruction should the nurse include?

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?

A client with a new diagnosis of glaucoma is concerned about going blind. To help prevent blindness due to glaucoma, the nurse should instruct the client to implement which action(s)? Select all that apply.

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?