A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure? The nurse assesses the client after a thoracentesis. Which assessment finding warrants immediate action? You should have 2 responses for this question: 1 for Intervention and 1 for Assessment.
Assessment: The trachea is shifted away from the midline of the neck.
Assessment: Pulse oximetry is 93% on 2 L of oxygen.
Assessment: The client rates pain as 8/10 at the site of the procedure.
Intervention: Request an order for pain medication.
Intervention: Measure oxygen saturation before and after a 12-minute walk.
Intervention: Explain the procedure in detail to the client and the family.
Intervention: Assist the client to the bathroom.
Intervention: Discuss all possible complications with the client.
Assessment: A small amount of drainage from the site is noted.
Intervention: Validate that informed consent has been given by the client.
Correct Answer : A,J
Intervention: Validate that informed consent has been given by the client.
Reason: Before any invasive procedure, it is crucial to ensure that the client has given informed consent. This means the client understands the procedure, its risks, benefits, and any potential complications. Validating informed consent is a legal and ethical requirement that ensures the client is making an informed decision about their care12.
Assessment: The trachea is shifted away from the midline of the neck.
Reason: A tracheal shift is a critical finding that warrants immediate action. It can indicate a tension pneumothorax, which is a life-threatening condition where air accumulates in the pleural space and causes the lung to collapse. This shift can compromise respiratory function and requires urgent intervention34.
Choice B: Pulse oximetry is 93% on 2 L of oxygen.
Reason: While a pulse oximetry reading of 93% on 2 liters of oxygen is slightly below the normal range (95-100%), it is not immediately life-threatening. However, it does indicate that the client may need further evaluation and monitoring to ensure adequate oxygenation.
Choice C: The client rates pain as 8/10 at the site of the procedure.
Reason: Pain management is important, but an 8/10 pain rating at the procedure site, while significant, does not require immediate action compared to a tracheal shift. Pain can be managed with appropriate analgesics as ordered by the physician.
Choice D: Request an order for pain medication.
Reason: Requesting an order for pain medication is a necessary intervention for managing the client’s pain, but it is not as urgent as addressing a tracheal shift. Pain management should be part of the overall care plan.
Choice E: Measure oxygen saturation before and after a 12-minute walk.
Reason: Measuring oxygen saturation before and after a 12-minute walk is a useful assessment to evaluate the client’s respiratory function and endurance. However, it is not an immediate priority compared to ensuring informed consent and addressing critical findings.
Choice F: Explain the procedure in detail to the client and the family.
Reason: Explaining the procedure in detail to the client and their family is essential for informed consent and reducing anxiety. It ensures that the client understands what to expect and can make an informed decision about their care.
Choice G: Assist the client to the bathroom.
Reason: Assisting the client to the bathroom is a routine nursing intervention that ensures the client’s comfort and dignity. However, it is not a priority compared to addressing critical findings and ensuring informed consent.
Choice H: Discuss all possible complications with the client.
Reason: Discussing all possible complications with the client is part of the informed consent process. It ensures that the client is aware of potential risks and can make an informed decision about their care.
Choice I: A small amount of drainage from the site is noted.
Reason: Noting a small amount of drainage from the site is an important assessment, but it is not as urgent as addressing a tracheal shift. The drainage should be monitored and documented, and any significant changes should be reported to the physician.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Nonfat milk is generally considered safe for individuals with GERD. While full-fat dairy products can exacerbate GERD symptoms due to their high-fat content, nonfat milk does not have this effect. It is low in fat and unlikely to trigger acid reflux. Therefore, nonfat milk is not a food that needs to be avoided by someone with GERD.
Choice B Reason:
Apples are typically safe for individuals with GERD. In fact, non-citrus fruits like apples are often recommended as part of a GERD-friendly diet. They are low in acid and unlikely to cause reflux symptoms. Therefore, apples do not need to be avoided by someone with GERD.
Choice C Reason:
Chocolate is a common trigger for GERD symptoms. It contains caffeine and theobromine, both of which can relax the lower esophageal sphincter (LES), allowing stomach acid to escape into the esophagus and cause reflux. Additionally, chocolate is high in fat, which can further exacerbate GERD symptoms. Therefore, it is advisable for individuals with GERD to avoid chocolate to prevent worsening of their symptoms.
Correct Answer is ["B"]
Explanation
Choice A Reason:
I sleep at least 8 hours each night.
This statement is not concerning because getting adequate sleep is generally a sign of good health. It does not directly relate to symptoms of high blood glucose levels. Therefore, this choice is not relevant to the nurse’s concerns regarding the client’s elevated blood glucose level.
Choice B Reason:
I cannot seem to quench my thirst.
This statement is concerning because excessive thirst, known as polydipsia, is a common symptom of high blood glucose levels or hyperglycemia. When blood glucose levels are elevated, the body tries to eliminate the excess glucose through urine, leading to dehydration and increased thirst. This symptom indicates that the client’s blood glucose levels may be poorly controlled, which requires medical attention.
Choice C Reason:
I have to void nearly every hour.
Frequent urination, or polyuria, is another symptom of high blood glucose levels. When there is too much glucose in the blood, the kidneys work harder to filter and absorb it. When they can’t keep up, the excess glucose is excreted into the urine, pulling fluids from the tissues and causing frequent urination. This symptom is a clear indicator of hyperglycemia and needs to be addressed by the nurse.
Choice D Reason:
At times my vision is blurry.
Blurred vision can be a symptom of high blood glucose levels. Elevated glucose levels can cause the lens of the eye to swell, leading to changes in vision. This symptom is concerning because it suggests that the client’s blood glucose levels are affecting their vision, which can be a sign of poorly managed diabetes or other complications.
Choice E Reason:
I have lost 10 pounds without even trying.
Unintentional weight loss is a concerning symptom of high blood glucose levels. When the body cannot use glucose for energy due to insulin resistance or lack of insulin, it starts to break down muscle and fat for energy, leading to weight loss. This symptom indicates that the client’s diabetes may be uncontrolled, and immediate medical intervention is necessary.
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