A nurse is assisting a provider with a client who is to undergo a thoracentesis.
In which of the following positions should the nurse place the client?

Supine with the head of the bed flat.

Trendelenburg with the head flexed.

Sitting upright while leaning forward over pillows.

Lying prone with arms extended away from body.

Answer and Explanation

The Correct Answer is C

Choice A rationale

The supine position with the head of the bed flat does not facilitate the safe and effective draining of fluid from the pleural cavity. This position can compromise the respiratory status of the patient and is therefore not suitable for a thoracentesis.

Choice B rationale

The Trendelenburg position, where the head is lower than the feet, can increase intracranial pressure and is not suitable for thoracentesis. This position does not allow for the optimal access to the pleural space needed for the procedure.

Choice C rationale

Sitting upright while leaning forward over pillows is the ideal position for a thoracentesis. This position allows the fluid to accumulate at the base of the pleural cavity and provides easy access for the procedure. It also facilitates better breathing and reduces the risk of injury to the diaphragm and other internal structures.

Choice D rationale

Lying prone with arms extended away from the body does not provide adequate access to the pleural space for thoracentesis. This position also makes it difficult to manage and monitor the patient's respiratory status during the procedure. .

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Correct Answer is A

Explanation

Choice A rationale

Ensuring the weights hang freely prevents interference with the traction, which helps maintain alignment and reduce pain.

Choice B rationale

Maintaining 6.8 kg (15 lb) of weight is not specific to skin traction and could be inappropriate, as the weight should be based on the physician's orders.

Choice C rationale

Loosening the ropes of the pulleys when repositioning the client can interfere with the effectiveness of the traction.

Choice D rationale

Inspecting the client's skin every 12 hours for signs of breakdown is not frequent enough; skin should be checked more often to prevent complications.

A. Monitor for at least 150 mL of drainage every hour. B. Replace the unit when the drainage chamber is full. C. Clamp the tube for 30 min every 8 hr. D. Pin the tubing to the client's bed sheets.

Correct Answer is B

Explanation

Choice A rationale

Monitoring for at least 150 mL of drainage every hour is excessive; the expected drainage is around 70-100 mL per hour. This amount indicates a potential complication.

Choice B rationale

Replacing the unit when the drainage chamber is full is correct to maintain the efficiency of the closed-chest tube drainage system and prevent overflow.

Choice C rationale

Clamping the tube for 30 minutes every 8 hours can cause tension pneumothorax and is not recommended.

Choice D rationale

Pinning the tubing to the client's bed sheets can cause kinks and obstruction, which can lead to complications.

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A nurse is assisting a provider with a client who is to undergo a thoracentesis.In which of the following positions should the nurse place the client?

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A nurse is assisting a provider with a client who is to undergo a thoracentesis.
In which of the following positions should the nurse place the client?