A nurse is planning care for a client who is scheduled for a thoracentesis.

Which of the following actions should the nurse plan to take

Instruct the client to avoid coughing during the procedure

Inform the client that he will be NPO for 6 hr prior to the procedure

Position the client on the affected side for 4 hr following the procedure.

Place the client in the prone position during the procedure

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Instruct the client to avoid coughing during the procedure.

A thoracentesis is a procedure that involves inserting a needle into the pleural space to remove excess fluid or air. Coughing can increase the risk of pneumothorax (collapsed lung) or bleeding during the procedure.

Choice B is wrong because the client does not need to be NPO (nothing by mouth) for 6 hr prior to the procedure. There is no risk of aspiration during a thoracentesis.

Choice C is wrong because the client should be positioned on the unaffected side for 4 hr following the procedure. This allows the affected lung to re-expand and prevents fluid from accumulating in the pleural space again.

Choice D is wrong because the client should not be placed in the prone position during the procedure. The prone position makes it difficult to access the pleural space and can compromise breathing.

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Correct Answer is B

Explanation

Obtain the specimen from the retention port. This is because the retention port is a sterile site that can be accessed by a syringe to aspirate urine without contaminating the specimen or the closed drainage system. The retention port should be cleaned with an alcohol swab before inserting the syringe. The specimen should be transferred to a sterile container and labeled appropriately.

Choice A is wrong because unclamping the collection port below the bag would allow urine to flow out of the bag, which is not sterile and may contain bacteria or sediment. Choice C is wrong because disconnecting the catheter from the collection tubing would break the closed drainage system and increase the risk of infection. Choice D is wrong because using the balloon port to obtain the sterile specimen would deflate the balloon that holds the catheter in place and cause trauma to the bladder wall.

Normal ranges for urine characteristics vary depending on the type of analysis, but some general parameters are:

Color: pale yellow to amber
Clarity: clear or slightly cloudy
Odor: faint aromatic
pH: 4.5 to 8.0
Specific gravity: 1.005 to 1.030
Protein: <150 mg/24 hr
Glucose: negative
Ketones: negative
Blood: negative
Nitrites: negative
Leukocyte esterase: negative
Bacteria: <10,000 CFU/mL

A. Align a trochanter wedge between the client’s legs. B. Apply an orthotic to the client’s foot. C. Place a towel roll under the client’s neck. D. Position a pillow under the client’s knees. E. undefined

Correct Answer is B

Explanation

The correct answer is choice B. Applying an orthotic to the client’s foot.

An orthotic is a device that supports or corrects the function of a body part.

In this case, an orthotic can help prevent foot drop, which is a common contracture deformity in immobile patients.

Foot drop occurs when the muscles that lift the foot become weak or paralyzed, causing the foot to hang down at the ankle. An orthotic can keep the foot in a neutral position and prevent shortening of the calf muscles and Achilles tendon.

Choice A is wrong because a trochanter wedge is used to prevent external rotation of the hip, not contracture. A trochanter wedge is a triangular-shaped pillow that is placed between the legs to keep them parallel and aligned.

Choice C is wrong because a towel roll under the neck is used to maintain proper cervical alignment, not contracture. A towel roll can prevent hyperextension of the neck and support the natural curve of the spine.

Choice D is wrong because a pillow under the knees can actually cause contracture of the knee joint by keeping it in a flexed position. A pillow under the knees can also reduce blood flow to the lower extremities and increase the risk of deep vein thrombosis.

Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.

Contracture can limit the range of motion and function of the affected body part. Contracture can be caused by inactivity, scarring, or diseases that affect the muscles or nerves. Prevention of contractures requires early diagnosis and initiation of physical medicine approaches such as passive range of motion exercises and splinting before contractures are present or while contractures are mild.

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A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take

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A nurse is planning care for a client who is scheduled for a thoracentesis.

Which of the following actions should the nurse plan to take