Patient Data
Exhibits
The healthcare provider (HCP) would like to do a thoracentesis on the client. The client's caregiver asks the nurse if there are any contraindications for the procedure.
Performing a thoracentesis is contraindicated in which clinical manifestation (s)? Select all that apply.

Unstable hemodynamics

Coagulation deficiencies

Hypertension

Mechanical ventilation required

Tracheal deviation

Infection

Answer and Explanation

Correct Answer : A,B

Rationale:
A. Unstable hemodynamics: Performing a thoracentesis in a client with unstable blood pressure or cardiac output increases the risk of circulatory collapse. Fluid removal can further compromise venous return and perfusion, making hemodynamic stability a critical prerequisite for the procedure.

B. Coagulation deficiencies: Clients with coagulopathies, such as low platelet counts or elevated INR, face a high risk of bleeding into the pleural space or chest wall during thoracentesis. Correction of clotting abnormalities is necessary before proceeding to prevent hemothorax or uncontrolled bleeding.

C. Hypertension: Elevated blood pressure alone is not a contraindication for thoracentesis. It may require monitoring and control, but it does not inherently increase procedural risk unless accompanied by other cardiovascular instability.

D. Mechanical ventilation required: Clients on mechanical ventilation can safely undergo thoracentesis when carefully monitored, although it requires expert technique to prevent pneumothorax. The need for mechanical ventilation is not an absolute contraindication.

E. Tracheal deviation: Tracheal deviation is often a sign of mediastinal shift or large pleural effusion, not a reason to avoid thoracentesis. In fact, the procedure may help relieve pressure by removing excess pleural fluid.

F. Infection is incorrect because systemic infection alone is not a strict contraindication; however, infection at the puncture site would be a concern, but this option is too general.

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Correct Answer is B

Explanation

Rationale:
A. The football player’s girlfriend is crying and screaming for help: Emotional distress from bystanders is common in emergencies but does not directly endanger the injured person. While the nurse may need to calm her later, it is not the most urgent issue.

B. A fellow football player is encouraging the victim to try and sit up: Encouraging movement in a client with a potential neck or spinal injury can cause further spinal cord damage or paralysis. The nurse must immediately stop this action, maintain cervical spine immobilization, and ensure that emergency services are called.

C. Several friends are walking around the accident victim and staring at him: Although this may interfere with rescue efforts or crowd control, it poses no immediate physical threat to the injured client. It can be managed after ensuring spinal precautions are in place.

D. One of the friends is calling a relative to tell them about the accident: Contacting the family is appropriate once emergency services have been alerted and care is being provided. This action does not interfere with the client’s immediate safety or neurological stability.

A. Use a bed cradle to support linen above the legs. B. Use a Doppler ultrasound to reassess the pulses. C. Elevate the extremities above the level of the heart. D. Wrap the lower extremities with warm blankets.

Correct Answer is B

Explanation

Rationale:
A. Use a bed cradle to support linen above the legs: A bed cradle helps prevent pressure from linens on the legs, but it does not address absent or difficult-to-palpate pulses. This intervention is supportive but not diagnostic or priority-focused.

B. Use a Doppler ultrasound to reassess the pulses: When pedal pulses cannot be palpated, a Doppler allows accurate assessment of blood flow and perfusion. Prompt evaluation is essential to detect potential arterial compromise or postoperative complications, such as thrombosis or edema-related vascular obstruction.

C. Elevate the extremities above the level of the heart: Elevation reduces edema but may worsen arterial perfusion if pulses are already absent. Before positioning, confirming circulation with Doppler assessment ensures interventions do not exacerbate ischemia.

D. Wrap the lower extremities with warm blankets: Warming may improve comfort and circulation slightly, but it does not provide objective assessment of vascular status or address potential postoperative vascular compromise.

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Patient Data Exhibits The healthcare provider (HCP) would like to do a thoracentesis on the client. The client's caregiver asks the nurse if there are any contraindications for the procedure. Performing a thoracentesis is contraindicated in which clinical manifestation (s)? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A young man playing football in the park sustains a hard hit and is lying motionless on the ground, while his friends are trying to help him. Which action by his friends warrants immediate intervention by the nurse who was watching from the sidelines?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

The nurse is completing a head to toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?

A client's telemetry monitor indicates ventricular fibrillation (VF). Which should the nurse do first?

A young adult male client is admitted to the emergency department (ED) following a motor vehicle collision and the nurse suspects that he has suffered a spinal cord injury (SCI). Which assessment finding, if present, will alert the nurse to suspect spinal shock?

Patient Data Exhibits The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.

A client's chest tube becomes dislodged from the drainage system. Which action should the nurse take?

Patient Data
Exhibits
The healthcare provider (HCP) would like to do a thoracentesis on the client. The client's caregiver asks the nurse if there are any contraindications for the procedure.
Performing a thoracentesis is contraindicated in which clinical manifestation (s)? Select all that apply.