The client is a young male who appears to be 25-30 years old. He was found unconscious on a sidewalk by a jogger who was passing. The jogger called an ambulance, and the EMT's transported the ent to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT CT of the head in the emergency room showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.

The PN reinforces education about seizures to the client and asks him to explain what he understands about his condition.

Which statements indicate understanding?

Select all that apply

The practical nurse (PN) should include the following actions when assessing a client for signs and symptoms of fluid volume excess:

• Palpate the rate and volume of the pulse: Fluid volume excess can lead to an increased pulse rate and bounding pulse due to the increased blood volume.
• Measure body weight at the same time daily: Monitoring daily weights can help identify fluid retention or weight gain, which can be indicative of fluid volume excess.
• Observe the color and amount of urine: Changes in urine color and output can provide information about kidney function and fluid balance. In fluid volume excess, urine output may be increased and urine may appear pale or diluted.

The following options are incorrect:

• Check fingernails for the presence of clubbing: Clubbing of the fingernails is not directly related to fluid volume excess. It is a finding commonly associated with chronic respiratory conditions and certain cardiac disorders.
• Compare muscle strength of both arms: Assessing muscle strength is not directly related to fluid volume excess. It is more relevant when evaluating neurological or musculoskeletal conditions.

A. Gather the procedure tray and equipment – The practical nurse should gather all necessary supplies for the healthcare provider to perform the thoracentesis efficiently. Preparing the equipment beforehand ensures that the procedure can start promptly and reduces interruptions for missing supplies.

Rationale for Incorrect Answers:
B. Cleanse the site and cover with a sterile towel – This action should be performed by the healthcare provider immediately before the procedure to maintain sterility. The PN’s role is to prepare equipment and ensure the client is positioned correctly.

C. Keep the patient NPO (nothing by mouth) and encourage them to void – While voiding may be encouraged before some procedures to improve client comfort, it is not necessary for thoracentesis. Additionally, keeping the client NPO is not required, as the procedure does not typically involve sedation that would necessitate this restriction.

D. Place the patient in an orthopneic position – This may be done just before the procedure, but the healthcare provider typically directs the final positioning. Initial positioning or seating at the bedside can be done, but orthopneic positioning should follow the provider’s instructions.