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 B

Explanation

A. "I can season food with ketchup.": Ketchup is high in sodium and not suitable.
B. "I can season food with vinegar.": Vinegar is low in sodium and appropriate for clients managing hypertension.
C. "I can have a bologna sandwich.": Processed meats like bologna are high in sodium and should be avoided.
D. "I can have canned soup.": Canned soups often contain excessive sodium, making them inappropriate.

A. Encourage socialization as a distractor when the client becomes agitated. B. Limit instructions to two steps at a time. C. Vary the staff providing care for the client D. Encourage independence in ADLs.

Correct Answer is B

Explanation

A. "Encourage socialization as a distractor when the client becomes agitated.": Socialization might exacerbate agitation; calm environments and redirection are better strategies.
B. "Limit instructions to two steps at a time.": Simplified instructions accommodate the cognitive limitations of Alzheimer’s clients, reducing confusion and frustration.
C. "Vary the staff providing care for the client.": Consistent caregivers are essential for maintaining familiarity and reducing anxiety in clients with Alzheimer's disease.
D. "Encourage independence in ADLs.": Independence should only be encouraged as much as the client can manage safely; overemphasis might lead to frustration or harm.

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