A nurse is assisting with the care of a client.
The vital signs indicate abnormalities.
Which of the following actions should the nurse take?

Administer IV fluids as prescribed.

Place the client in a supine position.

Monitor for signs of infection.

Notify the provider about abnormal findings.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Administering IV fluids as prescribed can be essential for maintaining fluid balance, but it does not directly address abnormal vital signs unless they are linked to hypovolemia. The nurse should prioritize identifying the cause of the abnormalities first, and then proceed with interventions aimed at stabilization and correction.

Choice B rationale

Placing the client in a supine position can exacerbate certain conditions, such as respiratory distress or hypoxia. While position changes may be needed in specific cases, this is not a primary action for addressing abnormal vital signs unless positional changes are directly implicated.

Choice C rationale

Monitoring for signs of infection is an important ongoing care strategy, especially when abnormal findings suggest potential sepsis. However, it alone does not resolve immediate concerns with abnormal vital signs and must be paired with communication and treatment strategies.

Choice D rationale

Promptly notifying the provider about abnormal findings ensures that the client's condition is evaluated comprehensively. Providers can order additional assessments or interventions to address potential underlying issues, thereby preventing clinical deterioration.

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Correct Answer is B

Explanation

Choice A rationale

Remaining flat in bed post-thoracentesis can impair respiratory function by reducing lung expansion. Proper positioning facilitates pleural fluid clearance and reduces dyspnea risk. Elevating the head enhances ventilation and drainage, improving post-procedural recovery and minimizing complications.

Choice B rationale

Post-procedure chest x-rays confirm successful fluid removal and monitor for complications like pneumothorax, common after pleural interventions. Imaging validates lung re-expansion and ensures pleural integrity, critical for addressing new or worsening respiratory distress symptoms.

Choice C rationale

Aseptic, not clean technique, minimizes infection risk during thoracentesis. Sterile precautions protect against bacterial introduction into the pleural space, which can cause empyema, a severe complication. All materials and the procedure field should meet sterile standards.

Choice D rationale

Urinary catheter insertion is unrelated to thoracentesis and poses unnecessary infection risks. The procedure focuses on resolving pleural fluid issues, and urinary monitoring is not standard unless clinically indicated for other medical concerns. .

A. Echinacea. B. Ginkgo biloba. C. Probiotics. D. Flaxseed powder.

Correct Answer is B

Explanation

Choice A rationale

Echinacea enhances immune function but has minimal effects on coagulation. It is not commonly associated with adverse interactions with anticoagulants like enoxaparin unless paired with other supplements causing significant immune changes.

Choice B rationale

Ginkgo biloba poses an increased bleeding risk due to antiplatelet effects, which can compound the anticoagulant properties of enoxaparin. This interaction necessitates close monitoring and communication with the provider.

Choice C rationale

Probiotics aid gastrointestinal health without influencing coagulation pathways or interacting significantly with anticoagulants. They are generally safe to continue unless contraindicated by other clinical factors.

Choice D rationale

Flaxseed powder contains omega-3 fatty acids, which may have mild anticoagulant properties. However, this interaction is usually not clinically significant unless used in large quantities alongside other anticoagulants. .

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A nurse is assisting with the care of a client.The vital signs indicate abnormalities.Which of the following actions should the nurse take?

Nursing Test Bank

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A nurse is assisting with the care of a client.
The vital signs indicate abnormalities.
Which of the following actions should the nurse take?