A client is scheduled for a thoracentesis that will be done at the bedside. What should the practical nurse (PN) prepare before the healthcare provider arrives to perform the procedure?

Gather the procedure tray and equipment.

Cleanse the site and cover with a sterile towel.

Keep the patient NPO (nothing by mouth) and encourage them to void.

Place the patient in an orthopneic position.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Gather the procedure tray and equipment.

Choice A rationale:

The practical nurse should gather the necessary procedure tray and equipment to ensure everything is ready for the healthcare provider to perform the thoracentesis efficiently and safely.

Choice B rationale:

Cleansing the site and covering it with a sterile towel is part of the procedure itself and should be done by the healthcare provider performing the thoracentesis.

Choice C rationale:

Keeping the patient NPO (nothing by mouth) and encouraging them to void is not necessary for a thoracentesis. This procedure typically does not require the patient to be NPO.

Choice D rationale:

Placing the patient in an orthopneic position (sitting up and leaning forward) is important for the procedure, but it should be done closer to the time of the procedure, not necessarily as a preparatory step.

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Correct Answer is C

Explanation

Choice A rationale:

Ketonuria is not a common complication of diabetes insipidus. Ketonuria is associated with diabetes mellitus, a different condition that results in the accumulation of ketones in the urine due to insufficient insulin.

Choice B rationale:

Peripheral edema is also an unlikely complication of diabetes insipidus. Diabetes insipidus is characterized by excessive thirst and urination, not fluid retention or peripheral edema.

A. 24-hour intake at the current infusion rate. B. Serum potassium level of 3.1 mEq/L (3.1 mmol/L). C. Gastric output of 900 mL in the last 24 hours. D. Increased blood urea nitrogen (BUN).

Correct Answer is B

Explanation

Choice A rationale:

Reporting the 24-hour intake at the current infusion rate is not the most important finding to report to the healthcare provider in this case. It is essential to monitor intake and output, but a single report of the 24-hour intake is not as critical as other findings.

Choice B rationale:

Reporting a serum potassium level of 3.1 mEq/L (3.1 mmol/L) is the most important finding to report to the healthcare provider. The patient's potassium level is below the normal range, indicating hypokalemia. Hypokalemia can have serious cardiac and neuromuscular effects, including arrhythmias and muscle weakness. Prompt intervention, such as potassium supplementation or adjustment of IV fluids, is necessary to address this potentially life-threatening condition.

Choice C rationale:

Reporting a gastric output of 900 mL in the last 24 hours is significant and should be reported to the healthcare provider, but it is not as urgent as the low potassium level. Gastric output should be monitored to assess for signs of improvement or worsening, but hypokalemia takes precedence due to its immediate health risks.

Choice D rationale:

Reporting an increased blood urea nitrogen (BUN) is important for the overall assessment of the patient's renal function but is not the most critical finding in this scenario. The low potassium level is a more immediate concern and requires immediate attention.

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A client is scheduled for a thoracentesis that will be done at the bedside. What should the practical nurse (PN) prepare before the healthcare provider arrives to perform the procedure?

Nursing Test Bank

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