The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed?

Prone with a pillow under the head

Lying on the unaffected side

In the high Fowler's position

In the supine position

Answer and Explanation

The Correct Answer is C

A. Prone with a pillow under the head: The prone position is not appropriate after thoracentesis as it can restrict chest expansion and complicate breathing, especially after removal of pleural fluid.
B. Lying on the unaffected side: This position may be used in certain cases, such as after a lung biopsy, but is not the standard post-thoracentesis position. It doesn’t promote optimal lung expansion or drainage.
C. In the high Fowler's position: High Fowler's position allows for maximum lung expansion and ease of breathing. It also helps facilitate drainage of any remaining pleural fluid and is the preferred position after thoracentesis.
D. In the supine position: Lying flat may impair respiratory effort, especially in clients who just had fluid removed from the pleural space. This position is not ideal for respiratory recovery post-procedure.

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Correct Answer is D

Explanation

A. Transfer the client to the emergency department: Transferring the client delays immediate airway management, which is critical. This action is not appropriate as the first step because airway patency must be addressed on the spot to prevent respiratory distress.
B. Call for the registered nurse to reinsert the tube: While notifying the RN is important, maintaining the airway takes precedence. Waiting for another provider before taking action risks closure of the stoma and airway compromise.
C. Cover the tracheostomy site with a sterile gauze to prevent infection: Covering the site without maintaining patency could cause the stoma to close rapidly. Infection control is important, but it is secondary to preserving the airway.
D. Place a dilator in the stoma to maintain the opening: Inserting a tracheostomy dilator prevents the stoma from closing and buys time for reinsertion of the tube. This is the immediate priority to ensure the airway remains open and the client can breathe effectively.

A. "I have gained a lot of weight." B. "I eat even when I am not hungry." C. "I eat slowly but consistently throughout the day." D. "I always feel guilty after I overeat."

Correct Answer is B

Explanation

A. "I have gained a lot of weight.": Weight gain can occur with binge eating disorder but is not diagnostic by itself. Many factors can contribute to weight gain, and it doesn’t confirm disordered eating patterns.
B. "I eat even when I am not hungry.": Binge eating disorder is characterized by recurrent episodes of consuming large amounts of food, often without physical hunger. This behavior reflects loss of control over eating and is a key diagnostic feature.
C. "I eat slowly but consistently throughout the day.": This pattern suggests grazing, not binge eating. Binge episodes typically involve eating rapidly, in secret, and until uncomfortably full, which is not described here.
D. "I always feel guilty after I overeat.": Feelings of guilt may accompany binge eating, but emotional response alone is not diagnostic. The behavioral pattern of eating large amounts when not hungry is more definitive of the disorder.

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The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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