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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Having the client point their chin upward to swallow is not a recommended action to reduce the risk of aspiration. In fact, this action can increase the risk of choking and aspiration, as it may cause food or liquids to enter the airway.
Choice B rationale:
Offering the client saltine crackers between meals is not a suitable action for reducing the risk of aspiration. Saltine crackers are dry and can be challenging to swallow for someone with dysphagia, potentially increasing the risk of aspiration.
Choice C rationale:
Thicken liquids before serving is the correct action to reduce the risk of aspiration in a client with dysphagia. Thickened liquids are easier to swallow and less likely to enter the airway, reducing the risk of aspiration pneumonia.
Choice D rationale:
Placing food on the affected side of the mouth does not address the risk of aspiration directly. Dysphagia may affect both sides of the mouth, and placing food on one side does not ensure safe swallowing and reduces the effectiveness of addressing the problem.
Correct Answer is C
Explanation
Choice A rationale:
Increasing the intake of high-fiber foods is not relevant to addressing the client's dry mouth caused by benztropine. High-fiber foods are commonly recommended for managing constipation, a symptom often associated with Parkinson's disease, but it does not address the issue of dry mouth.
Choice B rationale:
Chewing sugarless gum can stimulate saliva production and help alleviate dry mouth. However, it is not the most appropriate recommendation for a client taking benztropine, as gum-chewing may interfere with the effectiveness of the medication or exacerbate other symptoms.
Choice C rationale:
Moistening the mouth with lemon-glycerin swabs is the most suitable recommendation for a client experiencing dry mouth due to benztropine. Lemon-glycerin swabs can help increase saliva production and provide relief from the discomfort of dry mouth without interfering with the medication's efficacy.
Choice D rationale:
Rinsing the mouth with nystatin is used to treat fungal infections in the mouth (oral thrush) and is not relevant to address the side effect of dry mouth caused by benztropine.
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