The nurse assists a patient into which position in preparation for a diagnostic thoracentesis?
Sitting upright with elbows on an over-bed table and feet supported
Sitting in bed with knees slightly flex and feet flexed
Lying flat in the fetal position on the unaffected side
Lying flat on the unaffected side with knees slightly flexed
The Correct Answer is A
A. The optimal position for a thoracentesis is sitting upright with the patient leaning forward slightly, with elbows resting on an over-bed table to help expose the pleural space for access. This position allows gravity to pull the lungs downward and facilitates easier access to the pleural cavity.
B. Sitting in bed with knees slightly flexed and feet flexed is not the best position for thoracentesis. This position might limit the ability to properly expose the thoracic cavity for the procedure.
C. Lying flat in the fetal position on the unaffected side would not allow for effective drainage or access to the pleural space and is not ideal for thoracentesis.
D. Lying flat on the unaffected side with knees slightly flexed is not ideal because it does not provide optimal positioning for the procedure. The upright position is preferred for thoracentesis to facilitate easy access to the pleural space.
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Related Questions
Correct Answer is C
Explanation
A. The client exhales as the medication is released from the inhaler: This is incorrect. The client should inhale deeply while activating the inhaler. Exhaling before inhaling will reduce the effectiveness of the medication.
B. The client takes a quick inhalation while releasing the medication from the inhaler: This is incorrect. The client should inhale slowly and deeply to allow the medication to reach the lungs effectively. A quick inhalation may result in less medication being delivered to the lungs.
C. The client holds his breath for 10 seconds after inhaling the medication: This is the correct action. Holding the breath allows the medication to settle in the lungs, enhancing its therapeutic effect.
D. The client waits 10 min between inhalations: This is not necessary unless instructed by the healthcare provider. Most guidelines suggest waiting 1 to 2 minutes between inhalations of the same medication.
Correct Answer is D
Explanation
A. While documenting the amount of drainage is important, it is not the most urgent action when clear drainage is observed after a transsphenoidal hypophysectomy.
B. Notifying the provider is important but should not be the first step. The nurse should first assess the nature of the drainage, as it could indicate a serious complication, such as cerebrospinal fluid (CSF) leakage.
C. A culture may be necessary if infection is suspected, but the priority action is to assess whether the drainage is CSF.
D. Checking the drainage for glucose is the most appropriate initial action. Clear drainage from the nasal packing could indicate a CSF leak, which is a complication that can occur after transsphenoidal surgery. CSF contains glucose, so testing for glucose in the drainage will help determine if it is CSF. If glucose is detected, the nurse should immediately notify the provider, as CSF leakage requires prompt intervention.
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