A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse?

Describe the sensations the client will feel during the procedure.

Reinforce the importance of lying still during the procedure.

Administer a sedative medication.

Determine whether the client has an allergy to local anesthetics.

Answer and Explanation

The Correct Answer is D

The priority intervention for the nurse is to determine whether the client has an allergy to local anesthetics, as this could cause a serious adverse reaction during the procedure.

Thoracentesis is a minimally invasive procedure that involves inserting a needle into the pleural space to drain excess fluid or air from around the lungs. The procedure requires local anesthesia to numb the area where the needle is inserted. Therefore, it is essential to assess for any allergy to local anesthetics before proceeding with the procedure.

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Correct Answer is A

Explanation

The nurse's priority is to ensure that the client has given informed consent for the surgery, which requires that the client is competent and understands the risks and benefits of the procedure. A client with a high blood alcohol level may not have the mental capacity to consent and may need a legal representative or a court order to proceed with the surgery.

The other actions are important but not as urgent as obtaining consent.

A. Protamine sulfate B. Acetylcysteine C. Vitamin K D. Flumazenil

Correct Answer is A

Explanation

Protamine sulfate is an antidote for heparin overdose and can reverse its anticoagulant effects. It should be available at the bedside in case of bleeding complications or heparin toxicity. The nurse should monitor the client's activated partial thromboplastin time (aPTT) and adjust the heparin infusion rate accordingly.

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A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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