A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure? The nurse assesses the client after a thoracentesis. Which assessment finding warrants immediate action? You should have 2 responses for this question: 1 for Intervention and 1 for Assessment.
Assessment: The trachea is shifted away from the midline of the neck.
Assessment: Pulse oximetry is 93% on 2 L of oxygen.
Assessment: The client rates pain as 8/10 at the site of the procedure.
Intervention: Request an order for pain medication.
Intervention: Measure oxygen saturation before and after a 12-minute walk.
Intervention: Explain the procedure in detail to the client and the family.
Intervention: Assist the client to the bathroom.
Intervention: Discuss all possible complications with the client.
Assessment: A small amount of drainage from the site is noted.
Intervention: Validate that informed consent has been given by the client.
Correct Answer : A,J
Intervention: Validate that informed consent has been given by the client.
Reason: Before any invasive procedure, it is crucial to ensure that the client has given informed consent. This means the client understands the procedure, its risks, benefits, and any potential complications. Validating informed consent is a legal and ethical requirement that ensures the client is making an informed decision about their care12.
Assessment: The trachea is shifted away from the midline of the neck.
Reason: A tracheal shift is a critical finding that warrants immediate action. It can indicate a tension pneumothorax, which is a life-threatening condition where air accumulates in the pleural space and causes the lung to collapse. This shift can compromise respiratory function and requires urgent intervention34.
Choice B: Pulse oximetry is 93% on 2 L of oxygen.
Reason: While a pulse oximetry reading of 93% on 2 liters of oxygen is slightly below the normal range (95-100%), it is not immediately life-threatening. However, it does indicate that the client may need further evaluation and monitoring to ensure adequate oxygenation.
Choice C: The client rates pain as 8/10 at the site of the procedure.
Reason: Pain management is important, but an 8/10 pain rating at the procedure site, while significant, does not require immediate action compared to a tracheal shift. Pain can be managed with appropriate analgesics as ordered by the physician.
Choice D: Request an order for pain medication.
Reason: Requesting an order for pain medication is a necessary intervention for managing the client’s pain, but it is not as urgent as addressing a tracheal shift. Pain management should be part of the overall care plan.
Choice E: Measure oxygen saturation before and after a 12-minute walk.
Reason: Measuring oxygen saturation before and after a 12-minute walk is a useful assessment to evaluate the client’s respiratory function and endurance. However, it is not an immediate priority compared to ensuring informed consent and addressing critical findings.
Choice F: Explain the procedure in detail to the client and the family.
Reason: Explaining the procedure in detail to the client and their family is essential for informed consent and reducing anxiety. It ensures that the client understands what to expect and can make an informed decision about their care.
Choice G: Assist the client to the bathroom.
Reason: Assisting the client to the bathroom is a routine nursing intervention that ensures the client’s comfort and dignity. However, it is not a priority compared to addressing critical findings and ensuring informed consent.
Choice H: Discuss all possible complications with the client.
Reason: Discussing all possible complications with the client is part of the informed consent process. It ensures that the client is aware of potential risks and can make an informed decision about their care.
Choice I: A small amount of drainage from the site is noted.
Reason: Noting a small amount of drainage from the site is an important assessment, but it is not as urgent as addressing a tracheal shift. The drainage should be monitored and documented, and any significant changes should be reported to the physician.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Title: Choice A Reason:
Patients with seafood allergies may have a higher risk of allergic reactions to iodinated contrast media used in CT scans. However, this is not a definitive contraindication. The nurse should inform the patient to notify their healthcare provider about any known allergies, including seafood, as a precautionary measure. This allows the healthcare team to take necessary steps to prevent any adverse reactions, such as premedication with antihistamines or corticosteroids.
Title: Choice B Reason:
Metformin is a common medication used to manage type II diabetes. When a patient is scheduled for a CT scan with IV contrast, it is crucial to withhold Metformin before the procedure. This is because the combination of Metformin and iodinated contrast can increase the risk of contrast-induced nephropathy (CIN) and lactic acidosis, a rare but serious condition. The general recommendation is to stop Metformin at the time of or prior to the procedure and withhold it for 48 hours after the procedure, resuming only after renal function has been re-evaluated and found to be normal.
Title: Choice C Reason:
CT scans, especially those requiring IV contrast, are typically performed in a radiology suite equipped with the necessary technology and medical personnel. Performing such a procedure at the bedside is uncommon and not standard practice due to the need for specialized equipment and immediate access to emergency care in case of adverse reactions. Therefore, this statement is incorrect.
Title: Choice D Reason:
Taking Metformin as usual before the test is not recommended due to the risk of lactic acidosis when combined with iodinated contrast. As previously mentioned, Metformin should be withheld before and after the procedure until renal function is confirmed to be normal. This precaution helps to prevent any potential complications associated with the interaction between Metformin and the contrast agent.
Correct Answer is C
Explanation
Choice A: Severe Hypertension
Severe hypertension can be a sign of increased intracranial pressure (ICP), but it is not typically the earliest sign. Hypertension often occurs as a compensatory mechanism to maintain cerebral perfusion pressure. While it is a significant finding, it usually follows other more immediate signs of increased ICP.
Choice B: Dilated and Nonreactive Pupils
Dilated and nonreactive pupils are a late sign of increased ICP and indicate severe brainstem compression. This finding suggests that the pressure has reached a critical level, leading to brain herniation. It is a very serious sign but not the earliest indicator of increasing ICP.
Choice C: Decreased Level of Consciousness
A decreased level of consciousness is often the earliest and most sensitive indicator of increasing ICP. Changes in consciousness can range from confusion and lethargy to complete unresponsiveness. This symptom reflects the brain’s response to increased pressure and reduced cerebral perfusion, making it a critical early sign that requires immediate attention.
Choice D: Projectile Vomiting
Projectile vomiting can occur with increased ICP due to pressure on the vomiting centers in the brainstem. However, it is not typically the earliest sign. Vomiting often accompanies other symptoms such as headache and changes in consciousness.
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