A nurse is assisting a provider with a thoracentesis for a client who is experiencing respiratory distress. Which of the following actions should the nurse take?

Insert an indwelling urinary catheter and record the client's output.

Set up the equipment using clean technique.

Prepare the client for a chest x-ray following the procedure.

Instruct the client to remain flat in bed for 4 to 6 hr after the procedure.

Answer and Explanation

The Correct Answer is C

A. "Insert an indwelling urinary catheter and record the client's output.": This is not relevant to a thoracentesis, which focuses on the pleural cavity, not urinary output.
B. "Set up the equipment using clean technique.": Sterile technique is required to prevent infection during the invasive procedure.
C. "Prepare the client for a chest x-ray following the procedure.": A chest x-ray is performed post-thoracentesis to ensure the lung has re-expanded and to rule out complications like pneumothorax.
D. "Instruct the client to remain flat in bed for 4 to 6 hr after the procedure.": The client does not need to remain flat; instead, they are typically observed for respiratory complications in a sitting or semi-Fowler’s position.

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Correct Answer is ["A","B","C","D"]

Explanation

A. Blood pressure: The client’s blood pressure (92/60 mm Hg) is low, which is concerning, especially with tachycardia (HR 106). This may indicate hypovolemia or shock, which requires immediate attention.
B. BUN level: The BUN level (25 mg/dL) is elevated above the normal range, which could indicate dehydration or kidney dysfunction, often seen in conditions like gastrointestinal obstruction or sepsis.
C. Potassium level: The potassium level (3.3 mEq/L) is below the normal range (3.5 to 5 mEq/L), which can contribute to arrhythmias and muscle weakness, often a result of vomiting, diarrhea, or dehydration.
D. Abdominal findings: The high-pitched bowel sounds and tenderness are consistent with an intestinal obstruction, and further assessment and intervention are necessary to manage the condition effectively.
E. WBC count: The WBC count (9,000/mm³) is within the normal range, suggesting no active infection or inflammation at the moment.
F. Breath sounds: Bilateral breath sounds are clear, which suggests no current respiratory issues or pneumonia, allowing the focus to remain on gastrointestinal findings.

A. The client had a hemorrhoidectomy 1 year ago. B. The client takes ibuprofen for headaches. C. The client consumed citrus juice 3 days before the test. D. The client has a history of breast cancer.

Correct Answer is B

Explanation

A. Hemorrhoidectomy is not likely to cause a false-positive test, as the wound would typically heal and stop bleeding after a year.
B. The client takes ibuprofen for headaches: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can irritate the gastrointestinal (GI) tract, leading to minor bleeding in the stomach or intestines, which can result in a false-positive fecal occult blood test.
C. Citrus juice may alter the pH of the stool but is not a known cause of false-positive results in fecal occult blood tests.
D. Breast cancer is not directly associated with causing false-positive results in fecal occult blood tests.

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A nurse is assisting a provider with a thoracentesis for a client who is experiencing respiratory distress. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assisting with the care of a client. Exhibits The nurse is collecting data on the client. Which of the following findings require follow-up? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?

Correct Answer is B

Explanation

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