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?

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

Set up the equipment using clean technique.

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

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

Answer and Explanation

The Correct Answer is C

A. "Insert an indwelling urinary catheter and record the client's output.": This is not relevant to a thoracentesis, which focuses on the pleural cavity, not urinary output.
B. "Set up the equipment using clean technique.": Sterile technique is required to prevent infection during the invasive procedure.
C. "Prepare the client for a chest x-ray following the procedure.": A chest x-ray is performed post-thoracentesis to ensure the lung has re-expanded and to rule out complications like pneumothorax.
D. "Instruct the client to remain flat in bed for 4 to 6 hr after the procedure.": The client does not need to remain flat; instead, they are typically observed for respiratory complications in a sitting or semi-Fowler’s position.

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Correct Answer is D

Explanation

A. "You will need to fast for 2 hours before the procedure." Bone marrow aspiration typically does not require fasting. If the procedure involves sedation, the client may be instructed to fast for a certain period, but fasting is not a standard requirement for bone marrow aspiration.
B. "You will have the bone marrow taken from your femur." While the femur (thigh bone) can be a site for bone marrow aspiration, the most common site is the posterior iliac crest (the back of the pelvis). The nurse should clarify the exact site with the healthcare provider.
C. "You will not receive a local anesthetic agent for this procedure." Bone marrow aspiration is typically performed under local anesthesia to minimize discomfort at the site. The client will feel pressure during the procedure but should not experience pain due to the anesthesia.
D. "I will hold pressure on the site after the procedure." After a bone marrow aspiration, the nurse will apply pressure to the site to control any bleeding and help prevent hematoma formation. This is an important part of post-procedure care.

A. "It is common for the skin on my breasts to dimple. B. "I will perform breast exams every other month." C. "It is common for one breast to be larger than the other D. "I will perform breast exams the day my period begins."

Correct Answer is C

Explanation

A. "It is common for the skin on my breasts to dimple": Dimpling can be a sign of breast cancer due to underlying tissue changes and should be evaluated.
B. "I will perform breast exams every other month": BSE should be done monthly to detect any changes early.
C. "It is common for one breast to be larger than the other." Slight asymmetry between breasts is normal and not a cause for concern unless there is a sudden change.
D. "I will perform breast exams the day my period begins": BSE should be done 5-7 days after the menstrual period starts when hormonal swelling has subsided.

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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

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is to undergo a bone marrow aspiration. Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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