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 D

Explanation

Choice A rationale:

The nurse should not instruct the older adult client with osteoporosis to increase high-impact activities. Osteoporosis is a condition characterized by decreased bone density and strength, making high-impact activities potentially harmful as they could increase the risk of fractures.

Choice B rationale:

The nurse should not advise the client to consume a low-protein diet. Adequate protein intake is essential for maintaining muscle mass and overall musculoskeletal health, especially in older adults who may be at risk of muscle wasting.

Choice C rationale:

The nurse should not encourage the client to maintain a BMI of 30 to 35. A BMI within this range is considered obese and can put additional stress on the musculoskeletal system, increasing the risk of joint problems and other health issues.

Choice D rationale:

Including fiber in the diet is a correct instruction for promoting musculoskeletal health. Fiber-rich foods can help maintain bowel regularity and prevent constipation, which is important for overall comfort and mobility in older adults with osteoporosis.

A. Poor skin turgor. B. Fruity breath odor. C. Kussmaul respirations. D. Irritability.

Correct Answer is D

Explanation

Choice A rationale:
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
Choice B rationale:
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
Choice C rationale:
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
Choice D rationale:
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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