The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

Anticipate a stinging feeling during needle insertion.

Prepare to sit forward with arms propped on a table.

Expect a persistent cough after the procedure.

Limit activity for a day or two after returning home.

Answer and Explanation

The Correct Answer is C

Rationale

A. During a thoracentesis, a needle is inserted through the chest wall into the pleural space to remove fluid or air. It's common for clients to feel a stinging sensation or discomfort during needle insertion. The nurse should confirm this understanding with the client and reassure them that local anesthesia will be used to minimize discomfort.

B. The positioning described (sitting forward with arms propped on a table) helps to expand the intercostal spaces and facilitates easier access to the pleural space during the procedure. The nurse should reinforce this position as appropriate for the thoracentesis procedure.

C. This statement is incorrect and would indicate a need for additional education. A persistent cough is not an expected outcome after a thoracentesis. While some clients may experience a mild cough during or immediately after the procedure due to irritation from the needle or local anesthesia, it should not persist afterwards.

D. This statement is generally correct. After a thoracentesis, it is recommended to limit strenuous activity and avoid heavy lifting for a day or two to minimize the risk of complications such as discomfort or injury at the needle insertion site. The nurse should support this instruction as part of the client's post-procedure care.

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Correct Answer is C

Explanation

Rationale

A. While it is important background information, it is not directly relevant to the acute change in the client's condition (increasing confusion and agitation). Therefore, this should not be provided first in the SBAR communication.

B. Knowing the client's current medications is important for understanding any potential causes or exacerbating factors related to the sudden onset of confusion and agitation. However, this is also background information and does not immediately address the acute change in the client's condition.

C. This is the most critical piece of information to provide first in the SBAR communication. Sudden onset of increasing confusion and agitation can indicate various urgent issues such as delirium, infection, metabolic disturbances, or neurological complications. This requires immediate attention and intervention from the healthcare provider.

D. While knowing the client's healthcare power of attorney is important for ensuring appropriate decision-making if needed, it is not urgent information in the context of reporting a sudden change in the client's condition. This can be discussed later in the SBAR communication or as part of the background information if relevant to the client's care.

Correct Answer is ["1.3"]

Explanation

Convert pounds to kilograms.

1 pound = 0.453592 kilograms
132 pounds * 0.453592 kg/pound = 59.87 kilograms

Step 2: Calculate the total dose in micrograms.

44 micrograms/kilogram * 59.87 kilograms = 2635.08 micrograms

Step 3: Convert micrograms to milligrams.

1 milligram = 1000 micrograms
2635.08 micrograms / 1000 micrograms/milligram = 2.63508 milligrams

Step 4: Calculate the volume to be administered.

Concentration of lorazepam = 2 milligrams/milliliter
Volume = Dose / Concentration
Volume = 2.63508 milligrams / 2 milligrams/milliliter = 1.31754 milliliters

Therefore, the nurse should administer approximately 1.3milliliters of the lorazepam solution.

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The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is ["1.3"]

Explanation

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