A nurse is planning care for a client who is scheduled for a thoracentesis.
Which of the following actions should the nurse plan to take
Instruct the client to avoid coughing during the procedure
Inform the client that he will be NPO for 6 hr prior to the procedure
Position the client on the affected side for 4 hr following the procedure.
Place the client in the prone position during the procedure
The Correct Answer is A
The correct answer is choice A. Instruct the client to avoid coughing during the procedure.
A thoracentesis is a procedure that involves inserting a needle into the pleural space to remove excess fluid or air. Coughing can increase the risk of pneumothorax (collapsed lung) or bleeding during the procedure.
Choice B is wrong because the client does not need to be NPO (nothing by mouth) for 6 hr prior to the procedure. There is no risk of aspiration during a thoracentesis.
Choice C is wrong because the client should be positioned on the unaffected side for 4 hr following the procedure. This allows the affected lung to re-expand and prevents fluid from accumulating in the pleural space again.
Choice D is wrong because the client should not be placed in the prone position during the procedure. The prone position makes it difficult to access the pleural space and can compromise breathing.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Determine the client’s Glasgow Coma Scale score. This is because the Glasgow Coma Scale (GCS) is a tool to assess the level of consciousness and neurological status of a client who has a closed head injury. The GCS score can help guide the priority of interventions and the need for further diagnostic tests.
Choice A is wrong because an MRI of the brain is not the first action to take for a client who has a closed head injury. An MRI may be indicated later to evaluate the extent of brain damage, but it is not an emergency procedure.
Choice B is wrong because mannitol IV bolus is a medication that reduces intracranial pressure (ICP) by drawing fluid out of the brain tissue. However, mannitol should not be administered before confirming the presence and degree of increased ICP, which can be done by measuring the GCS score and other vital signs.
Choice D is wrong because inserting an indwelling urinary catheter for the client is not the first action to take for a client who has a closed head injury. A urinary catheter may be needed to monitor fluid balance and renal function, but it is not an urgent intervention.
Correct Answer is A
Explanation
Choice A reason:
"Plan to take this medication with food." Is the correct statement. When providing instructions to an older adult client who has a seizure disorder and is prescribed phenytoin (an antiepileptic or anticonvulsant medication), the nurse should advise the client to take the medication with food. Phenytoin can cause gastrointestinal irritation, and taking it with food can help minimize this side effect.
Choice B reason:
"Plan to take this medication with antacids. “is not the appropriate instruction. Phenytoin should not be taken with antacids. Antacids can reduce the absorption of phenytoin, leading to decreased effectiveness of the medication. If antacids are needed for other reasons, they should be taken at least 2 hours before or after taking phenytoin.
Choice C reason:
"Limit foods that contain vitamin D while taking this medication. “This is not inappropriate instruction. There is no specific requirement to limit foods containing vitamin D while taking phenytoin. However, phenytoin may decrease the absorption of vitamin D, which could potentially affect the client's vitamin D levels. Therefore, it is essential for the client to have regular check-ups and possibly discuss the need for vitamin D supplementation with their healthcare provider.
Choice D reason:
"Limit foods that contain folic acid while taking this medication. “This is not the correct statement. Phenytoin can interfere with the absorption of folic acid (a B-vitamin). Long-term use of phenytoin may lead to folic acid deficiency. Therefore, the nurse should instruct the client to consume foods rich in folic acid and discuss the potential need for folic acid supplementation with their healthcare provider.
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