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 []
Explanation
Potential condition: Opioid-induced constipation
Actions to take
Administer a stool softener: Opioids commonly cause constipation by slowing down bowel motility and increasing water absorption in the intestines. A stool softener can help by adding moisture to the stool, making it easier to pass.
Ask the client about their normal bowel routine: Understanding the client's typical bowel habits can provide insights into any deviations caused by the surgery or medication.
Parameters to monitor
Fluid intake: Monitoring the client's fluid intake is crucial as adequate hydration helps maintain bowel function and prevents constipation.
Serum potassium level: Constipation, especially if severe or prolonged, can lead to electrolyte imbalances such as hypokalemia (low potassium levels), which can have serious health implications.
Correct Answer is D
Explanation
A. This information is crucial as it provides insight into the client's abdominal assessment post- laparotomy. A soft abdomen with absent bowel sounds suggests normal bowel function has not yet returned, which is common after abdominal surgery. However, this does not have immediate postoperative implications.
B. A history of vomiting prior to surgery could indicate a gastrointestinal issue that may impact the client’s recovery or increase the risk of complications such as nausea and vomiting postoperatively.However, this history may not immediately affect the current postoperative care as much as some other findings (such as changes in bowel sounds or bleeding) in the acute postoperative period.
C. This information provides reassurance regarding circulation and mobility of the lower extremities. However, it may not be as urgent to report immediately unless there were concerns during surgery or potential complications related to positioning or circulation.
D.This should be reported to ensure that the client is receiving proper hydration and that their hydration status is carefully monitored. It’s especially important to monitor for dehydration or difficulties with oral intake following surgery.
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