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. "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.

A. "I can decrease my risk for a stroke by losing excess weight." B. "My risk for a stroke increases if my HbA1c level is 5 percent or less." C. "Having a total cholesterol level below 200 mg/dL increases my risk for a stroke." D. "My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke."

Correct Answer is A

Explanation

A. "I can decrease my risk for a stroke by losing excess weight.": Excess weight is a modifiable risk factor for stroke, and losing weight can improve glycemic control, blood pressure, and cholesterol levels, reducing stroke risk.
B. "My risk for a stroke increases if my HbA1c level is 5 percent or less.": An HbA1c level of 5% is excellent and indicates good glycemic control, which reduces stroke risk.
C. "Having a total cholesterol level below 200 mg/dL increases my risk for a stroke.": A cholesterol level below 200 mg/dL is desirable and lowers the risk of cardiovascular events, including stroke.
D. "My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke.": Glucocorticoids are not used to reduce stroke risk; they can actually increase blood sugar and cardiovascular risk if used long-term.

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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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