A nurse is assisting a provider with a thoracentesis for a client who is experiencing respiratory distress. Which of the following actions should the nurse take?

Instruct the client to remain flat in bed for 4 to 6 hr after the procedure.

Set up the equipment using clean technique.

Prepare the client for a chest x-ray following the procedure.

Insert an indwelling urinary catheter and record the client's output.

Answer and Explanation

The Correct Answer is C

A. Instruct the client to remain flat in bed for 4 to 6 hr after the procedure: Clients are usually positioned sitting upright or leaning forward during thoracentesis, and remaining flat for several hours afterward is not required. Proper positioning after the procedure is typically for comfort and monitoring, not strict bed rest.

B. Set up the equipment using clean technique: Thoracentesis is an invasive procedure that requires strict aseptic technique, not just clean technique, to prevent infection and contamination of the pleural space. Using only clean technique would increase the risk of complications.

C. Prepare the client for a chest x-ray following the procedure: A post-procedure chest x-ray is recommended to check for complications such as pneumothorax or lung collapse. This imaging ensures that any adverse effects are identified promptly and managed appropriately.

D. Insert an indwelling urinary catheter and record the client's output: Inserting a urinary catheter is not part of standard thoracentesis care unless the client has unrelated urinary needs. It does not contribute to the safety or effectiveness of the thoracentesis procedure.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Maintain hip abduction when turning the client: After a total hip arthroplasty, maintaining hip abduction prevents dislocation of the prosthesis. Positioning devices such as abduction pillows help keep the hip in a safe alignment during movement and turning.

B. Turn the client every 4 hr for 48 hr while on bed rest: Turning every 4 hours may be insufficient to prevent pressure injuries, and prolonged strict bed rest is generally discouraged. Early mobilization as tolerated is preferred to reduce complications such as DVT and pneumonia.

C. Have the client use an incentive spirometer every 4 hr: Incentive spirometry is important for preventing postoperative pulmonary complications, but it is not specific to hip replacement care. The priority is protecting the surgical site and joint integrity.

D. Instruct the client to bend from the hip when retrieving items from the floor: Bending at the hip increases the risk of hip dislocation. Clients should be taught to use a reacher or bend at the knees while keeping the hip in neutral alignment.

A. Probiotics B. Ginkgo biloba C. Echinacea D. Flaxseed powder

Correct Answer is B

Explanation

A. Probiotics: Probiotics support gut health and do not have significant anticoagulant effects. Their use does not increase bleeding risk or interact directly with enoxaparin, so reporting is not usually necessary.

B. Ginkgo biloba: Ginkgo biloba can increase the risk of bleeding by inhibiting platelet aggregation, which may potentiate the anticoagulant effect of enoxaparin. This combination can lead to serious bleeding complications, so the provider should be informed.

C. Echinacea: Echinacea primarily supports immune function and does not significantly affect coagulation or interact with enoxaparin. Reporting its use is not critical for anticoagulation safety.

D. Flaxseed powder: Flaxseed provides fiber and omega-3 fatty acids but has minimal anticoagulant effect. While it may slightly influence bleeding in large amounts, it is not as concerning as ginkgo and does not typically require immediate provider notification.

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A nurse is assisting a provider with a thoracentesis for a client who is experiencing respiratory distress. Which of the following actions should the nurse take?

Nursing Test Bank

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