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. Rib pain with deep inspiration: Rib pain suggests possible rib fracture or contusion, which can be painful but is not immediately life threatening unless accompanied by respiratory compromise or pneumothorax. It requires monitoring but not urgent life-saving action.

B. Diminished bilateral breath sounds: Decreased breath sounds on both sides may indicate a severe chest injury such as pneumothorax, hemothorax, or respiratory failure. This finding threatens oxygenation and ventilation, requiring immediate airway management and possibly chest tube insertion.

C. Generalized abdominal tenderness: While abdominal tenderness raises concern for internal bleeding or organ injury, it does not immediately impair ventilation or perfusion. It is serious but not as acutely life threatening as compromised breath sounds.

D. Nausea with projectile vomiting: Projectile vomiting may suggest increased intracranial pressure from head trauma, but the airway and breathing take priority. Airway obstruction or hypoxia from inadequate ventilation remains the most immediate life-threatening condition.

A. Place the client's feet on pillows while sleeping. B. Elevate head of bed to a semi-Fowler's position while asleep. C. Leave a glass water at the bedside for use during the night. D. Give a PRN dose of cough syrup or expectorant.

Correct Answer is B

Explanation

Rationale:
A. Place the client's feet on pillows while sleeping: Elevating the feet can reduce peripheral edema but does not alleviate nocturnal dyspnea or orthopnea associated with left ventricular failure. This intervention addresses circulation but not respiratory comfort.

B. Elevate head of bed to a semi-Fowler's position while asleep: Elevating the head reduces venous return to the heart, decreases pulmonary congestion, and relieves orthopnea. This position helps minimize nighttime coughing and shortness of breath, directly addressing symptoms of left ventricular failure.

C. Leave a glass of water at the bedside for use during the night: While hydration is important, water does not alleviate cardiac-related nocturnal symptoms and does not prevent fluid accumulation in the lungs causing cough or dyspnea.

D. Give a PRN dose of cough syrup or expectorant: Cough medications may temporarily relieve irritation but do not treat the underlying pulmonary congestion from left ventricular failure. Symptom management should focus on optimizing cardiac function and positioning rather than suppressing the cough.

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Body system	Findings
Cardiovascular	Pedal pulse of 2+ or better Blood pressure of 120/74 mm Hg Capillary refill of 4 seconds in lower extremities
Neurovascular	Skin that is pale, cool to touch Pupils equal and nonresponsive to light Absence of numbness or tingling in feet
Renal Perfusion	Creatinine of 1.2 mg/dL (106 mmol/L) Client has urine output of 1,600 mL in 24 hours Decreased blood urea nitrogen (BUN) level of 9.8 mg/dL (3.50 mmol/L)

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

Correct Answer is B

Explanation

A client with left ventricular failure complains of a hacking cough that worsens at night and further complains that shortness of breath sometimes occurs upon wakening. Which intervention should the nurse include in the bedtime preparation?

Correct Answer is B

Explanation

A client who sustained a head injury is alert and oriented to person, place, time, and situation, moves all extremities on command, has equal muscle strength bilaterally, and pupils are reactive to light. Which action should the nurse implement next?

A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the client for?

A client with a C-7 spinal cord injury (SCI) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

Patient Data Exhibits The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.

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.