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 D

Explanation

A. Butter: Butter is high in saturated fats, which can raise LDL cholesterol and increase the risk of cardiovascular disease. Regular use should be limited, especially in clients at risk for heart disease.

B. Vegetable shortening: Vegetable shortening contains high levels of trans fats and saturated fats, both of which contribute to atherosclerosis and increased cardiovascular risk. It is not recommended for heart-healthy cooking.

C. Lard: Lard is rich in saturated fat, which can elevate LDL cholesterol and promote plaque formation in arteries. It is not suitable for clients needing to reduce cardiovascular risk.

D. Canola oil: Canola oil is low in saturated fat and high in monounsaturated fats, which help lower LDL cholesterol and reduce cardiovascular risk. It is a heart-healthy option for cooking and aligns with dietary guidelines for preventing heart disease.

A. Include raw fruits and vegetables daily. B. Encourage three large meals a day. C. Provide low-calorie snacks between meals. D. Serve foods that are easy to swallow.

Correct Answer is D

Explanation

A. Include raw fruits and vegetables daily.: Raw produce can contain bacteria or contaminants that increase infection risk in a client with AIDS who may be immunocompromised. Foods should be cooked or washed thoroughly to reduce exposure to harmful pathogens.

B. Encourage three large meals a day.: Large meals can be difficult for clients with poor appetite, nausea, or fatigue, which are common in AIDS. Smaller, more frequent meals are better tolerated and help maintain adequate caloric intake.

C. Provide low-calorie snacks between meals.: Clients with AIDS often struggle with weight loss and elevated metabolic demands, so low-calorie snacks do not meet their nutritional needs. High-calorie, high-protein snacks help prevent muscle wasting and support energy levels. Low-calorie choices are insufficient.

D. Serve foods that are easy to swallow.: Clients with AIDS may experience oral pain, thrush, or swallowing difficulties, making soft or easy-to-swallow foods more comfortable. Providing such foods promotes adequate intake, reduces discomfort, and supports overall nutritional status.

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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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