A nurse is caring for a client who is scheduled for diagnostic thoracentesis. Which of the following actions should the nurse take when assisting with this test?
Instruct the client to take deep breaths during the test.
Assist the client to a prone position prior to the test.
Inform the client that the new onset of a cough is expected following the test.
Apply pressure to the client's puncture site after the test is complete.
The Correct Answer is D
Choice A rationale:
Instructing the client to take deep breaths during the test is not appropriate for a thoracentesis. This procedure involves the insertion of a needle into the pleural space to drain fluid or air, and taking deep breaths could interfere with the accuracy and safety of the procedure.
Choice B rationale:
Assisting the client to a prone position prior to the test is also incorrect. During a thoracentesis, the client is usually seated upright or in a slightly forward-leaning position to allow better access to the pleural space and improve breathing.
Choice C rationale:
Informing the client that the new onset of a cough is expected following the test is not accurate. While a cough can be a possible side effect, it is not a common or expected outcome of a thoracentesis.
Choice D rationale:
Applying pressure to the client's puncture site after the test is complete is the correct action. This helps to prevent bleeding and reduce the risk of pneumothorax (collapsed lung) by promoting clot formation at the site of the needle insertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
"I changed the floor plan of our home to accommodate my father's wheelchair.”.
Choice A rationale:
This statement indicates acceptance of the role change as a caregiver for the aging parents. Making changes to the home to accommodate the father's wheelchair demonstrates the client's willingness to adapt and provide a suitable environment for caregiving.
Choice B rationale:
Feeling stressed out and overwhelmed does not necessarily indicate acceptance of the role change. It may reflect the challenges and emotional burden that come with caregiving but does not necessarily signify acceptance.
Choice C rationale:
Expressing frustration with caregiving does not necessarily indicate acceptance of the role change. It is normal to feel frustrated at times, especially when dealing with chronic illnesses, but acceptance involves embracing the responsibilities that come with the role.
Choice D rationale:
While the statement shows a willingness to learn and adapt to caregiving, it does not explicitly indicate acceptance of the role change. Acceptance involves acknowledging and embracing the new responsibilities and challenges fully.
Correct Answer is B
Explanation
Choice A rationale:
A capillary refill of less than 1 second is a normal finding and indicates adequate peripheral perfusion. It is not a cause for concern in this postoperative client.
Choice B rationale:
The presence of a pulse deficit should be reported to the provider because it suggests a discrepancy between the apical and radial pulses, indicating potential cardiovascular compromise or inadequate arterial perfusion.
Choice C rationale:
A systolic blood pressure 10 points lower than before surgery can be a normal response to anesthesia or surgery and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.
Choice D rationale:
Pulse oximetry at 96% is within the normal range for oxygen saturation and does not warrant immediate reporting. However, if the client is experiencing respiratory distress or other concerning symptoms, it should be addressed promptly.
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