A client is scheduled for a thoracentesis that will be done at the bedside. What should the practical nurse (PN) prepare before the healthcare provider arrives on the unit to perform the procedure?
Place the client in an orthopneic position
Keep the client NPO and encourage to void.
Gather the procedure tray and equipment.
Cleanse the site and cover with a sterile towel.
The Correct Answer is C
The correct answer is Choice C:
Gather the procedure tray and equipment. Choice A rationale:
Placing the client in an orthopneic position (sitting upright and leaning forward) is not necessary for a thoracentesis procedure. The position may be uncomfortable for the client and does not facilitate the procedure.
Choice B rationale:
Keeping the client NPO (nothing by mouth) and encouraging them to void before the procedure is not directly relevant to a thoracentesis. NPO status might be indicated for other procedures requiring anesthesia but not for a bedside thoracentesis.
Choice C rationale:
This is the correct choice. The PN should prepare by gathering the procedure tray and equipment before the healthcare provider arrives to perform the thoracentesis. This ensures that all necessary items are readily available for the procedure.
Choice D rationale:
Cleansing the site and covering it with a sterile towel is a task usually performed by the healthcare provider who will be performing the thoracentesis. The PN's role is to prepare the necessary equipment and assist the provider during the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. Oriented to person only.
Choice A rationale:
A blood pressure of 144/84 mmHg is slightly elevated but not critically high. While it is important to monitor, it does not immediately impact the instructions for morning care.
Choice B rationale:
An oxygen saturation measurement of 95 to 96% is within the normal range and indicates adequate oxygenation. This is important to monitor but does not require specific changes to morning care instructions.
Choice C rationale:
Being oriented to person only indicates a significant alteration in the client’s cognitive status, which is crucial for the UAP to be aware of. This affects the client’s ability to understand and follow instructions, and may require additional supervision and safety measures during care.
Choice D rationale:
A urinary output of 50 mL/hour is within the normal range (typically 30-50 mL/hour is considered adequate). While it is important to monitor, it does not necessitate immediate changes to morning care instructions.
: 1
Correct Answer is C
Explanation
Choice A rationale:
Offering a high protein diet may not be appropriate for a client with hepatic failure. High protein intake can lead to the accumulation of ammonia in the bloodstream, worsening hepatic encephalopathy. Therefore, this choice is not the best intervention for the client.
Choice B rationale:
Performing range of motion exercises is important for clients with hepatic failure to prevent complications related to immobility. However, it does not directly address the client's elevated pulse rate and changes in mental status.
Choice C rationale:
Weighing the client every morning is essential in monitoring fluid status and identifying signs of fluid retention or dehydration, which are common in hepatic failure. Changes in weight can help detect early signs of worsening hepatic function.
Choice D rationale:
Providing only distilled water may not be appropriate for a client with hepatic failure. While it is essential to monitor fluid intake, restricting all fluids to only distilled water could lead to electrolyte imbalances and further complications. Monitoring overall fluid intake and type is important for these clients.
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