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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

The nurse should not advise the client with multiple sclerosis to schedule all physical activities for the morning hours. While some individuals with multiple sclerosis may experience increased fatigue later in the day, the best approach is to encourage the client to schedule activities at times when they feel the most energetic and to balance physical activity with rest throughout the day.

Choice B rationale:

Monitoring blood pressure is essential while taking fingolimod, a medication used to treat multiple sclerosis, as it can cause a transient decrease in heart rate and blood pressure.

Therefore, the nurse should include this statement in the teaching to ensure the client's safety and early detection of any issues.

Choice C rationale:

This is the correct statement to include in the teaching. Clients with multiple sclerosis should avoid rigorous activities that increase body temperature, as this can worsen their symptoms due to the sensitivity of demyelinated nerves to heat. Activities such as hot baths or engaging in strenuous exercise in hot weather should be avoided.

Choice D rationale:

Corticosteroids are not typically used as a long-term treatment for multiple sclerosis. Instead, they are used for short courses during exacerbations to reduce inflammation and manage acute symptoms. Long-term use of corticosteroids can lead to significant adverse effects, so the nurse should not include this statement in the teaching.

A. "Cut the opening on the skin barrier wafer to customize fit over the stoma.". B. "Empty the bag when it is three-fourths full of stool.". C. "The color of the stoma should be slightly purple.". D. "Cleanse the peristomal skin with moisturizing soap and water.".

Correct Answer is A

Explanation

Choice A rationale:
Properly cutting the opening on the skin barrier wafer to fit over the stoma is crucial to prevent any irritation or damage to the surrounding skin. A well-fitted wafer creates a seal around the stoma, reducing the risk of stool coming into contact with the skin, which can cause excoriation.
Choice B rationale:
Emptying the bag when it is three-fourths full of stool is unrelated to the education on colostomy care. This information was provided in the previous question () and is not relevant to colostomy care education.
Choice C rationale:
The color of the stoma should not be slightly purple. A healthy stoma should be pink or red, indicating a good blood supply. A purple or dark-colored stoma could indicate inadequate blood flow, which is a concern and requires immediate medical attention.
Choice D rationale:
Cleansing the peristomal skin with moisturizing soap and water is not the recommended approach. The nurse should use plain water or mild, non-moisturizing soap to clean the peristomal skin, as moisturizing soap may leave a residue that affects the adhesion of the skin barrier wafer.

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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?

Nursing Test Bank

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