The practical nurse (PN) is providing care for a client who is ordered nothing by mouth (NPO) after a small bowel resection. The client's nasogastric (NG) tube is connected to low intermitent suction. The client reports dizziness and tingling in digits.

Which assessment finding by the PN should be reported to the healthcare provider?

The correct answer is Choice C:

Gather the procedure tray and equipment. Choice A rationale:

Placing the client in an orthopneic position (sitting upright and leaning forward) is not necessary for a thoracentesis procedure. The position may be uncomfortable for the client and does not facilitate the procedure.

Choice B rationale:

Keeping the client NPO (nothing by mouth) and encouraging them to void before the procedure is not directly relevant to a thoracentesis. NPO status might be indicated for other procedures requiring anesthesia but not for a bedside thoracentesis.

Choice C rationale:

This is the correct choice. The PN should prepare by gathering the procedure tray and equipment before the healthcare provider arrives to perform the thoracentesis. This ensures that all necessary items are readily available for the procedure.

Choice D rationale:

Cleansing the site and covering it with a sterile towel is a task usually performed by the healthcare provider who will be performing the thoracentesis. The PN's role is to prepare the necessary equipment and assist the provider during the procedure.

The correct answer is choiceC. Health care proxy documentation.

Choice A rationale:

The name of the funeral home to contact is not immediately relevant during the admission assessment of a terminally ill client. This information can be collected later as part of end-of-life planning but is not critical for the initial assessment.

Choice B rationale:

While the contact information for the client’s next of kin is important for communication and support, it is not as crucial as health care proxy documentation for making immediate healthcare decisions.

Choice C rationale:

Health care proxy documentation is essential because it designates someone to make healthcare decisions on behalf of the client if they become unable to do so themselves.This ensures that the client’s healthcare preferences and decisions are respected and followed by the healthcare team.

Choice D rationale:

The client’s wishes regarding organ donation are important but are often included in the health care proxy documentation.This information is not as immediately critical as the health care proxy documentation during the admission assessment.