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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Correct Answer is C

Explanation

A. Provide the client with ice chips: The client is on NPO status in preparation for surgery. Offering ice chips could increase the risk of aspiration or delay surgical procedures, so this action is not appropriate at this time.

B. Discontinue nasogastric tube: The NG tube is necessary to decompress the stomach and relieve nausea from the small-bowel obstruction. Removing it before surgery or resolution of obstruction could worsen vomiting and distention, so discontinuation is not indicated.

C. Reinforce preoperative teaching: Preoperative teaching helps reduce anxiety, improve cooperation, and prepare the client for what to expect during and after the exploratory laparotomy. This action is appropriate and supports client safety and understanding.

D. Start the prescribed antibiotic: The prescription for Cefazolin is 2 g IV and is ordered "on call for surgery." This means the antibiotic should be administered just before the surgical procedure begins, to ensure therapeutic levels are present in the bloodstream when the incision is made.

A. Airborne B. Droplet C. Protective D. Contact

Correct Answer is D

Explanation

A. Airborne precautions apply to pathogens spread by small particles that remain suspended in the air, such as TB or measles. VRE does not spread via airborne transmission, so these precautions do not reduce risk of organism transfer through direct or indirect contact.

B. Droplet precautions are intended for infections spread through large respiratory droplets that fall quickly, as seen with influenza or meningitis. VRE primarily contaminates hands, equipment, and surfaces rather than being transmitted through coughing or sneezing.

C. Protective precautions are designed to protect immunocompromised clients from outside microorganisms. These precautions are not appropriate for clients already colonized or infected with VRE, as the focus is preventing the spread from the client to others.

D. Contact precautions prevent spread through direct touch or shared equipment, which is the main mode of VRE transmission. Using gloves, gowns, and dedicated equipment helps limit environmental contamination and reduces the likelihood of cross-infection.

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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?

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