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 C

Explanation

A. Obtain the client's peak expiratory flow volume: This is unnecessary in this context and not a routine assessment post-tonsillectomy.
B. Encourage the client to cough: Coughing can irritate the surgical site and increase the risk of bleeding.
C. Place the client in a semi-Fowler's position. Semi-Fowler's position promotes optimal airway clearance and reduces the risk of aspiration or airway obstruction.
D. Encourage the client to use a straw to sip cool liquids: Straws are contraindicated because the suction action can disrupt the surgical site and cause bleeding.

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

Correct Answer is D

Explanation

A. Clamp the tube for 30 min every 8 hr: Clamping a chest tube increases the risk of tension pneumothorax and is contraindicated unless ordered by a provider.
B. Pin the tubing to the client's bed sheets: Pinning can cause disconnection or kinking of the tubing, leading to drainage issues.
C. Monitor for at least 150 mL of drainage every hour: Drainage greater than 100 mL/hour, especially after the first hour, should be reported as it may indicate hemorrhage.
D. Replace the unit when the drainage chamber is full. A full drainage chamber must be replaced to ensure the system functions properly and prevents complications like backflow.

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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

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Correct Answer is D

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