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

Answer and Explanation

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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Correct Answer is D

Explanation

The correct answer is d. Evaluate functioning of the suction device.

Choice D rationale:

Prompt assessment of the suction device is crucial to determine if it's functioning properly.If the suction is inadequate,it can lead to gastric contents accumulating and potentially causing vomiting.
Assessing the suction device first allows for timely interventionif it's not working correctly,preventing further complications and discomfort for the client.

Choice A rationale:

Replacing the NG tube might be necessary if it's dislodged or blocked, but it shouldn't be the immediate action.
Evaluating the suction device first can help determine if the NG tube itself is the issue or if the problem lies with the suction.

Choice B rationale:

Providing oral hygiene care is important for comfort and to prevent aspiration, but it's not the priority intervention in this situation.
Addressing the cause of the vomiting, which could be related to suction malfunction, takes precedence.

Choice C rationale:

Administering an antiemetic might be helpful to control nausea and vomiting, but it doesn't address the underlying cause.
Evaluating the suction device first is essential to ensure proper gastric decompression and prevent further vomiting episodes.

A. Give cromolyn nebulized solution every 6 hr. B. Offer small amounts of clear liquids 6 hr following surgery. C. Apply a warm compress to the operative site once daily. D. Administer analgesics on a scheduled basis for the first 24 hr.

Correct Answer is D

Explanation

The correct answer is choice D. Administer analgesics on a scheduled basis for the first 24 hr.

This is because the child is at risk for developing peritonitis, which can cause severe abdominal pain.

Scheduled analgesics can provide better pain relief than PRN analgesics.

Choice A is wrong because the child should not be given anything by mouth until bowel sounds return, which can take up to 24 hr after surgery.

Giving clear liquids too soon can cause nausea, vomiting, and abdominal distension.

Choice B is wrong because cromolyn nebulized solution is used to prevent asthma attacks, not to treat appendicitis.

There is no indication that the child has asthma or needs this medication.

Choice C is wrong because applying a warm compress to the operative site can increase inflammation and infection risk.

A cold compress can be used to reduce swelling and pain, but only if prescribed by the provider.

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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

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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