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 C
Explanation
Choice A rationale:
Increasing potassium consumption is unrelated to cephalexin, an antibiotic. It is not a necessary precaution or action to take while on this medication.
Choice B rationale:
Applying lotion to the skin to relieve itching is not related to cephalexin use. Itching is not a common side effect of this antibiotic, so the client's statement indicates a misunderstanding of the teaching.
Choice C rationale:
Avoiding sun exposure is essential while taking cephalexin because it is known to cause photosensitivity reactions. Sun exposure can lead to severe skin reactions, so the client's statement indicates an understanding of the teaching.
Choice D rationale:
Keeping the medication refrigerated is not necessary for cephalexin oral suspension. It should be stored at room temperature unless specified otherwise by the manufacturer. The client's statement suggests a misunderstanding of the medication storage instructions.
Correct Answer is C
Explanation
Choice A rationale:
Expiratory rhonchi are typically associated with conditions such as chronic bronchitis or asthma but are not specific to pulmonary embolism.
Choice B rationale:
Petechiae over the lower extremities is not a characteristic finding in pulmonary embolism. Petechiae are tiny red or purple spots that appear due to bleeding under the skin and may be associated with other conditions like thrombocytopenia.
Choice C rationale:
The correct choice. Hemoptysis, which refers to coughing up blood, is a concerning finding in pulmonary embolism. It occurs due to the obstruction of blood flow in the pulmonary vasculature, leading to blood leaking into the lungs.
Choice D rationale:
Flattened neck veins are more likely to be observed in conditions associated with decreased venous return to the heart, such as hypovolemia or cardiac tamponade, and are not directly related to pulmonary embolism.
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