The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?
Anticipate a stinging feeling during needle insertion.
Prepare to sit forward with arms propped on a table.
Expect a persistent cough after the procedure.
Limit activity for a day or two after returning home.
The Correct Answer is C
Rationale
A. During a thoracentesis, a needle is inserted through the chest wall into the pleural space to remove fluid or air. It's common for clients to feel a stinging sensation or discomfort during needle insertion. The nurse should confirm this understanding with the client and reassure them that local anesthesia will be used to minimize discomfort.
B. The positioning described (sitting forward with arms propped on a table) helps to expand the intercostal spaces and facilitates easier access to the pleural space during the procedure. The nurse should reinforce this position as appropriate for the thoracentesis procedure.
C. This statement is incorrect and would indicate a need for additional education. A persistent cough is not an expected outcome after a thoracentesis. While some clients may experience a mild cough during or immediately after the procedure due to irritation from the needle or local anesthesia, it should not persist afterwards.
D. This statement is generally correct. After a thoracentesis, it is recommended to limit strenuous activity and avoid heavy lifting for a day or two to minimize the risk of complications such as discomfort or injury at the needle insertion site. The nurse should support this instruction as part of the client's post-procedure care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale
A. Evacuation centers often accommodate a large number of people in close proximity. This can lead to increased transmission of infectious agents, including those causing diarrheal illnesses, through person- to-person contact or contaminated surfaces.
B. Hurricanes can cause flooding, which may overwhelm sewage systems and lead to contamination of drinking water sources. Consuming water contaminated by sewage can introduce pathogens that cause diarrheal diseases, such as bacteria like Escherichia coli or viruses like norovirus.
C. Flood waters can contaminate food supplies in various ways, such as direct contact with contaminated water, improper storage, or inadequate cooking or refrigeration. Consuming
contaminated food can result in diarrheal illnesses due to ingestion of pathogens like bacteria or parasites.
D. Nosocomial infections refer to infections acquired in healthcare settings. In a disaster medical area, improper infection control practices or overcrowding can contribute to nosocomial transmission of infectious agents, including those causing diarrheal diseases. However, this option is less likely in the context of a client seeking treatment for diarrhea immediately upon arrival at the disaster medical area.
Correct Answer is B
Explanation
Rationale
A. Diarrhea and flatulence are common gastrointestinal side effects of statin medications like lovastatin. While uncomfortable for the client, these symptoms are typically not serious and do not require immediate follow-up unless severe or persistent.
B. Muscle pain, also known as myalgia, is a potential side effect of statin therapy. In some cases, statins can cause muscle inflammation (myositis) or more severe muscle breakdown (rhabdomyolysis), which can lead to serious complications such as kidney damage. If a client reports new or worsening muscle pain, especially if accompanied by weakness, tenderness, or dark urine, it requires immediate follow-up to assess for these potential complications.
C. Abdominal cramps can occur as a gastrointestinal side effect of statins but are generally not considered a serious adverse reaction. They may improve with time or adjustments in diet or medication administration timing.
D. Altered taste, such as a metallic taste, is a less common side effect of statin therapy. While it can be bothersome, it is usually not serious and does not typically require immediate follow-up unless severe or persistent.
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