A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure?

Prone with arms raised over the head.

Sitting, leaning forward over the bedside table.

High Fowler's position

Side-lying with knees drawn up to the chest.

Answer and Explanation

The Correct Answer is B

A. Prone with arms raised over the head.

This position involves lying face down with the arms raised over the head. It is not appropriate for thoracentesis because it does not provide easy access to the thoracic cavity, and it may compress the chest, making it difficult for the client to breathe comfortably during the procedure.

B. Sitting, leaning forward over the bedside table.

This is the correct choice. For thoracentesis, the client should be positioned sitting upright and leaning forward over the bedside table or supported by pillows. This position allows better access to the thoracic cavity and facilitates the removal of pleural fluid. Leaning forward also helps to open up the intercostal spaces, making it easier for the healthcare provider to insert the needle into the appropriate space between the ribs.

C. High Fowler's position.

The High Fowler's position involves the client sitting upright with the head of the bed elevated at a 90-degree angle. While this position may be used for other respiratory procedures or for comfort, it is not the optimal position for thoracentesis. It does not provide the same degree of access to the thoracic cavity as the sitting position with forward leaning.

D. Side-lying with knees drawn up to the chest.

This position involves lying on one side with the knees drawn up to the chest. It is not appropriate for thoracentesis because it does not provide access to the thoracic cavity, and it may obstruct the procedure. Additionally, this position may not be comfortable for the client during the procedure.

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Correct Answer is A

Explanation

A. Fatigue

When collecting data from a client with pulmonary tuberculosis (TB), the nurse should expect to observe fatigue as one of the common manifestations. TB is a bacterial infection caused by Mycobacterium tuberculosis, primarily affecting the lungs. Fatigue is a typical symptom experienced by individuals with TB, often resulting from the body's immune response to the infection, as well as the systemic effects of inflammation and tissue damage caused by the bacteria.

B. High fever in the early morning

While fever is a symptom of tuberculosis, it may not necessarily occur specifically in the early morning. Fever associated with TB can occur at any time of the day and may persist for weeks to months. The pattern of fever can vary among individuals and may not consistently occur in the early morning.

C. Edema

Edema, or swelling due to fluid accumulation in tissues, is not typically associated with pulmonary tuberculosis. Edema is more commonly observed in conditions such as heart failure, renal failure, or liver disease, rather than in TB.

D. Increased appetite

Increased appetite is not a typical finding in pulmonary tuberculosis. In fact, individuals with active TB infection often experience appetite loss and unintended weight loss due to factors such as decreased food intake, metabolic changes, and systemic inflammation associated with the infection.

A. Auscultate breath sounds at least every 2 hr. B. Perform range-of-motion exercises at least two to three times daily. C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day. D. Apply antiembolic stockings.

Correct Answer is D

Explanation

A. Auscultate breath sounds at least every 2 hours.

Regularly auscultating breath sounds is important for assessing respiratory status and detecting any signs of respiratory complications such as pneumonia or atelectasis. However, it is not the priority action in this scenario compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.

B. Perform range-of-motion exercises at least two to three times daily.

Range-of-motion exercises help prevent contractures and maintain joint mobility in immobile clients. While they are important for preventing musculoskeletal complications, they are not the priority action compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.

C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day.

Maintaining adequate hydration is important for overall health and prevention of complications such as urinary tract infections and constipation. However, it is not the priority action in this scenario compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.

D. Apply antiembolic stockings.

The priority action for the nurse to contribute to the plan of care for an immobile client is to apply antiembolic stockings. Immobility increases the risk of deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE). Antiembolic stockings (also known as compression stockings or TED stockings) help prevent venous stasis and decrease the risk of blood clots forming in the lower extremities. Therefore, applying antiembolic stockings is essential in mitigating the risk of potentially life-threatening complications associated with immobility.

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A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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