A nurse is caring for a client who is scheduled for diagnostic thoracentesis. Which of the following actions should the nurse take when assisting with this test?

Instruct the client to take deep breaths during the test.

Assist the client to a prone position prior to the test.

Inform the client that the new onset of a cough is expected following the test.

Apply pressure to the client's puncture site after the test is complete.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Instructing the client to take deep breaths during the test is not appropriate for a thoracentesis. This procedure involves the insertion of a needle into the pleural space to drain fluid or air, and taking deep breaths could interfere with the accuracy and safety of the procedure.

Choice B rationale:

Assisting the client to a prone position prior to the test is also incorrect. During a thoracentesis, the client is usually seated upright or in a slightly forward-leaning position to allow better access to the pleural space and improve breathing.

Choice C rationale:

Informing the client that the new onset of a cough is expected following the test is not accurate. While a cough can be a possible side effect, it is not a common or expected outcome of a thoracentesis.

Choice D rationale:

Applying pressure to the client's puncture site after the test is complete is the correct action. This helps to prevent bleeding and reduce the risk of pneumothorax (collapsed lung) by promoting clot formation at the site of the needle insertion.

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Correct Answer is A

Explanation

The client's daily peak expiratory flow (PEF) measures 85% above personal best.

Choice A rationale:

Salmeterol is a long-acting beta-agonist used to treat asthma. Improvement in the client's daily peak expiratory flow (PEF) of 85% above their personal best indicates effective bronchodilation and better asthma control.

Choice B rationale:

ABGs showing a pH level of 7.32 are not indicative of the effectiveness of salmeterol. ABG values assess the client's acid-base balance and gas exchange, but they do not directly reflect the action of the medication.

Choice C rationale:

A decrease in forced expiratory volume after treatment with medication indicates a lack of response to the therapy, not an effective outcome. It suggests the medication is not adequately controlling the client's asthma symptoms.

Choice D rationale:

Wheezing limited to expiration is not a clear indicator of medication effectiveness. Wheezing can be present in various respiratory conditions and is not solely associated with asthma control. Exhibit. The correct answer is choice B: Increase the rate of the infusion by 160 units/hr.

A. A defined area of cool, boggy skin. B. A shallow crater involving the epidermis. C. Reddened area that does not blanch. D. Undermining or tunneling of the skin.

Correct Answer is B

Explanation

Choice A rationale:

A defined area of cool, boggy skin is not indicative of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, usually appearing as a shallow open ulcer with a red-pink wound bed, without slough or bruising.

Choice B rationale:

A shallow crater involving the epidermis is characteristic of a stage 2 pressure injury. It presents as a partial-thickness skin loss with the loss of the epidermis, and the wound may be superficial and appear as an abrasion, blister, or shallow ulcer.

Choice C rationale:

The reddened area that does not blanch is more indicative of an early-stage pressure injury (Stage 1). In Stage 1, the skin remains intact, but there is non-blanch-able erythema indicating damage to the skin and underlying tissue.

Choice D rationale:

Undermining or tunneling of the skin is not specific to stage 2 pressure injuries. These features may be observed in more advanced stages of pressure injuries, such as stages 3 and 4, where there is full-thickness skin loss with damage to the subcutaneous tissue and underlying structures.

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A nurse is caring for a client who is scheduled for diagnostic thoracentesis. Which of the following actions should the nurse take when assisting with this test?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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