The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?

Chest tube insertion tray.

Intubation tray.

Ventilator.

Crash cart.

Answer and Explanation

The Correct Answer is A

A. Chest tube insertion tray: Thoracentesis may lead to complications like pneumothorax, especially in clients with lung disease such as emphysema. If air or fluid reaccumulates or lung collapse occurs, a chest tube may be urgently required to re-expand the lung and drain air or fluid buildup.

B. Intubation tray: While intubation may be needed in cases of severe respiratory failure, it is not the first-line equipment after an ineffective thoracentesis. It would only be used if the patient is unable to breathe adequately despite other interventions.

C. Ventilator: Mechanical ventilation is not immediately needed for a failed thoracentesis unless the client develops respiratory failure. It is a secondary measure if oxygenation cannot be maintained with basic support.

D. Crash cart: A crash cart is essential during cardiac arrest or life-threatening emergencies. It is not the most appropriate equipment to have specifically for an ineffective thoracentesis unless severe complications arise suddenly.

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Correct Answer is A

Explanation

A. Maintain strict intake and output: Maintaining strict intake and output is essential in septic shock to monitor renal function and ensure adequate perfusion. Decreased urine output can indicate worsening shock or kidney failure, which requires prompt intervention.

B. Assess warmth of extremities: Early signs of septic shock often include cool or mottled extremities due to poor circulation, which should be addressed more through perfusion monitoring than by focusing solely on warmth.

C. Keep head of bed raised 45 degrees: Elevating the head of the bed may be helpful in certain situations, but it is not the most critical intervention for septic shock. The priority is to ensure proper hemodynamic monitoring, fluid resuscitation, and organ perfusion.

D. Monitor blood glucose level: While monitoring blood glucose is important in critically ill clients, it is not the immediate priority in septic shock. Sepsis often causes hyperglycemia, but managing fluid resuscitation and organ perfusion is the most urgent intervention.

A. 1+ strength in left upper extremity B. Decreased range of motion C. Coolness of skin D. Reduced pulse distal to injury E. Pain with movement

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

Rationale:

1+ strength in left upper extremity: Reduced strength in the affected arm could indicate a humeral fracture, which can impair muscle function and strength. A rotator cuff injury could cause pain, but it doesn’t necessarily lead to a reduction in strength to the extent seen with a humeral fracture.
Decreased range of motion: Decreased range of motion is common with humeral fractures as the bone is likely immobilized and painful to move. A rotator cuff injury can also lead to decreased range of motion due to pain and limited ability to lift or rotate the arm.
Coolness of skin: Coolness to the skin could indicate poor circulation, which can occur if there is vascular injury related to a humeral fracture or if there is significant swelling causing compression of blood vessels.Coolness is less commonly associated with rotator cuff injuries unless there is concurrent trauma affecting blood flow.
Reduced pulse distal to injury: Reduced pulses can suggest vascular injury, which is more likely with a humeral fracture, especially if the bone fragments are displacing or compressing blood vessels.This is unlikely with a rotator cuff injury, as it primarily affects the tendons and muscles without significant impact on vascular structures.
Pain with movement: Pain with movement is a classic symptom of a fracture, particularly when moving the arm or shoulder area. Pain with movement is also a hallmark of a rotator cuff injury, especially when the arm is raised or rotated.

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The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Exhibits For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

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