The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?

Chest tube insertion tray.

Intubation tray.

Ventilator.

Crash cart.

Answer and Explanation

The Correct Answer is A

A. Chest tube insertion tray: Thoracentesis may lead to complications like pneumothorax, especially in clients with lung disease such as emphysema. If air or fluid reaccumulates or lung collapse occurs, a chest tube may be urgently required to re-expand the lung and drain air or fluid buildup.

B. Intubation tray: While intubation may be needed in cases of severe respiratory failure, it is not the first-line equipment after an ineffective thoracentesis. It would only be used if the patient is unable to breathe adequately despite other interventions.

C. Ventilator: Mechanical ventilation is not immediately needed for a failed thoracentesis unless the client develops respiratory failure. It is a secondary measure if oxygenation cannot be maintained with basic support.

D. Crash cart: A crash cart is essential during cardiac arrest or life-threatening emergencies. It is not the most appropriate equipment to have specifically for an ineffective thoracentesis unless severe complications arise suddenly.

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Correct Answer is C

Explanation

A. Request a spiritual advisor's consult: This may be helpful later but is not the nurse’s first responsibility. The immediate need is to support the spouse emotionally through the initial shock.

B. Encourage viewing of the body to accept the death: While this may eventually assist with acceptance, it can feel rushed or harsh if suggested before acknowledging the spouse’s current emotional state.

C. Provide support of the spouse's feelings: Denial is a normal initial reaction to grief. Supporting the spouse’s emotional response is the most appropriate and immediate nursing action.

D. Ask the relatives about how the spouse is coping: This shifts focus away from the grieving spouse, who is the primary concern at this moment and requires direct support.

A. Leakage of cerebral spinal fluid from the incisional site. B. Poor feeding and vomiting. C. Abdominal distention. D. WBC of 10,000/mm3 (10 x 10^ 9/L). E. Hyperactive bowel sounds.

Correct Answer is ["A","B","C"]

Explanation

A. Leakage of cerebral spinal fluid from the incisional site: Leakage of cerebrospinal fluid (CSF) from the incision site is a serious postoperative complication. It could indicate a shunt malfunction or infection, requiring immediate attention.

B. Poor feeding and vomiting: These symptoms may indicate increased intracranial pressure, which can result from a shunt malfunction or infection, both serious complications that need to be addressed immediately.

C. Abdominal distention: Abdominal distention in an infant with a VP shunt can indicate an issue with the peritoneal end of the shunt. This could be due to malabsorption of CSF in the peritoneal cavity, infection (peritonitis), or kinking/blockage of the catheter in the abdomen, leading to accumulation of fluid and distention.

D. WBC of 10,000/mm3 (10 x 10^9/L): A WBC count of 10,000/mm3 is within the normal range for a one-week-old infant. Therefore, this finding does not indicate infection or an inflammatory response and is not a concern in this case.

E. Hyperactive bowel sounds: Hyperactive bowel sounds are typically not associated with a VP shunt complication. This finding is generally indicative of gastrointestinal motility, which is not related to a shunt malfunction or infection.

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The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?

Correct Answer is C

Explanation

The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which finding(s) indicate a postoperative complication? Select all that apply. Reference Range: White blood cells (WBC) [9,000 to 10,000/mm3 (9 to 10 x 10^9 /L)]

Correct Answer is ["A","B","C"]

Explanation

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