A client is scheduled for a thoracentesis that will be done at the bedside. What should the practical nurse (PN) prepare before the healthcare provider arrives to perform the procedure?
Gather the procedure tray and equipment.
Cleanse the site and cover with a sterile towel.
Keep the patient NPO (nothing by mouth) and encourage them to void.
Place the patient in an orthopneic position.
The Correct Answer is A
The correct answer is choice A. Gather the procedure tray and equipment.
Choice A rationale:
The practical nurse should gather the necessary procedure tray and equipment to ensure everything is ready for the healthcare provider to perform the thoracentesis efficiently and safely.
Choice B rationale:
Cleansing the site and covering it with a sterile towel is part of the procedure itself and should be done by the healthcare provider performing the thoracentesis.
Choice C rationale:
Keeping the patient NPO (nothing by mouth) and encouraging them to void is not necessary for a thoracentesis. This procedure typically does not require the patient to be NPO.
Choice D rationale:
Placing the patient in an orthopneic position (sitting up and leaning forward) is important for the procedure, but it should be done closer to the time of the procedure, not necessarily as a preparatory step.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Obtaining a urine specimen for analysis is an important step in the assessment of the client with renal calculi. However, it is not the most immediate intervention when the client is experiencing severe flank pain and hematuria. Pain management should take precedence.
Choice B rationale:
This is the correct answer. Severe flank pain in a client with renal calculi is indicative of renal colic, which is typically excruciating. Administering a prescribed opioid analgesic is the priority to relieve the client's pain and distress.
Choice C rationale:
Straining the urine for the presence of stones is an essential nursing intervention to identify and collect any passed stones. However, it is not the most immediate action when the client is in severe pain. Pain management is the priority.
Choice D rationale:
Preparing the client for a prescribed computed tomography (CT) scan is an important diagnostic step to assess the location and size of the renal calculi. However, it is not the most immediate intervention when the client is in severe pain and distress. Pain management should come first.
Correct Answer is C
Explanation
Choice A rationale:
Referring the client to a social worker for support therapy may be premature at this stage. The client's initial reaction may be due to fear or anxiety about the diagnosis and self-administration of insulin. Pushing the client into therapy without assessing their readiness may not be appropriate.
Choice B rationale:
Encouraging the client to implement relaxation techniques assumes that the client is open to learning and just needs help with anxiety management. However, the client's refusal to have the nurse in the room suggests that they are not currently receptive to teaching. It's important to address the client's emotional state first.
Choice C rationale:
Leaving the client's room and returning later in the day is the most appropriate initial action. The client's loud refusal indicates a need for privacy and emotional space. By respecting the client's wishes and revisiting the teaching later, the nurse can establish trust and build a better rapport.
Choice D rationale:
Explaining that insulin is a life-saving drug is informative but may not be effective in this situation, as the client has already requested the nurse to leave the room. Providing information about the importance of insulin should come after establishing a therapeutic nurse-client relationship.
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