A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse?

Describe the sensations the client will feel during the procedure.

Reinforce the importance of lying still during the procedure.

Administer a sedative medication.

Determine whether the client has an allergy to local anesthetics.

Answer and Explanation

The Correct Answer is D

The priority intervention for the nurse is to determine whether the client has an allergy to local anesthetics, as this could cause a serious adverse reaction during the procedure.

Thoracentesis is a minimally invasive procedure that involves inserting a needle into the pleural space to drain excess fluid or air from around the lungs. The procedure requires local anesthesia to numb the area where the needle is inserted. Therefore, it is essential to assess for any allergy to local anesthetics before proceeding with the procedure.

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Correct Answer is B

Explanation

Choice a.This response may come across as challenging or confrontational. While the nurse is asking for more information, the phrasing could inadvertently put the client on the defensive. It doesn't validate the client's feelings and may not encourage a productive dialogue.

Choice b. “Suggesting peer support or mentorship from someone who has gone through a similar experience could be beneficial in some situations, as it may help the client feel less isolated.
Choice c. “Most people can adjust following this surgery.” may be true, but it does not acknowledge the client’s individual experience and feelings. It may also sound dismissive or minimizing of the client’s challenges.
Choice d. “You are upset. We can talk about this later.” may be intended to give the client some space, but it does not convey empathy or support. It may also make the client feel rejected or ignored.

A. Neck-vein distention B. Ankle edema C. Anorexia D. Hacking cough

Correct Answer is D

Explanation

A hacking cough, especially at night or when lying down, is a common manifestation of left-sided heart failure, as fluid accumulates in the lungs and causes pulmonary congestion and dyspnea. Neck-vein distention and ankle edema are more indicative of right-sided heart failure, as fluid backs up into the systemic circulation and causes peripheral edema and jugular venous pressure elevation. Anorexia may occur in either type of heart failure, but it is not specific to left-sided heart failure.

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A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse?

Nursing Test Bank

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