A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure?

Correct Answer: D

Rationale: The correct answer is D. Validating that informed consent has been given by the client is crucial before any invasive procedure to ensure the client understands the risks, benefits, and alternatives. It also respects the client's autonomy and right to make an informed decision. A: Measuring oxygen saturation before and after a 12-minute walk is not directly related to thoracentesis preparation. B: Verifying the client's understanding of complications is important but not the immediate priority before the procedure. C: Explaining the procedure to the client and family is essential but may not be the first step; ensuring informed consent comes before this step.

Correct Answer: A

Rationale: The correct answer is A: Antibiotics started before admission. This outcome demonstrates that the staff are meeting the goal for treating clients with community-acquired pneumonia because timely administration of antibiotics is crucial in managing this condition effectively. Starting antibiotics promptly helps to reduce the spread of infection and improve patient outcomes. Blood cultures obtained within 20 minutes (B) is important for diagnosing the specific pathogen causing pneumonia but does not directly reflect the treatment goal achievement. Chest x-ray within 30 minutes (C) is essential for diagnosis but does not indicate treatment success. Pulse oximetry on all clients (D) is important for monitoring oxygen levels but does not directly show if the treatment goal for pneumonia has been met.

Correct Answer: D

Rationale: In assessing a client with trauma to the upper airway, the nurse should prioritize identifying the presence of laryngospasm. Laryngospasm is a serious complication that can occur due to upper airway trauma, leading to a sudden closure of the vocal cords and obstruction of the airway. This can result in severe respiratory distress and requires immediate intervention to prevent respiratory failure. Therefore, recognizing and addressing laryngospasm is crucial in the care of a client with upper airway trauma. Regarding the incorrect options: - Pain when talking (Option A) may be a symptom of upper respiratory infections or conditions like pharyngitis, but it is not specific to trauma of the upper airway. - Burning in the throat (Option B) is more indicative of acid reflux or irritation, not a primary symptom of upper airway trauma. - Increased nasal swelling (Option C) suggests nasal congestion or allergies rather than trauma to the upper airway. In an educational context, understanding the specific symptoms and complications of upper airway trauma is essential for nurses caring for patients with respiratory issues. By knowing the key signs to assess and intervene upon, nurses can provide timely and effective care to prevent further respiratory compromise in patients with upper airway trauma.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A: Assist client to sit up on the side of the bed. This intervention is appropriate to be delegated to a nursing assistant because it is a basic task that falls within their scope of practice and does not require specialized training or clinical judgment. Option B, instructing the client to cough effectively, involves providing specific guidance on a therapeutic technique that requires more knowledge and skill, making it more appropriate for a nurse to perform. Option C, teaching the client to use incentive spirometry, involves education on a medical device and its proper use, which is beyond the scope of a nursing assistant's role. Option D, auscultating breath sounds every 4 hours, is a skilled nursing assessment task that requires clinical judgment to interpret findings. This task should be performed by a nurse who can analyze the data collected and make appropriate decisions based on the assessment findings. In an educational context, understanding the delegation of tasks is crucial for healthcare professionals to work effectively as a team. By clearly delineating roles and responsibilities based on skill levels and scopes of practice, patient care can be delivered safely and efficiently. Nursing assistants play a vital role in supporting patient care by carrying out delegated tasks under the supervision of licensed nurses, ensuring that each team member contributes to the overall well-being of the patient.

Correct Answer: D

Rationale: The correct answer is D) Small airway closure earlier in expiration. As individuals age, changes occur in the respiratory system that can impact secretion clearance. Small airway closure earlier in expiration is a common age-related change that can hinder the effective clearance of secretions from the lungs. This closure can lead to air trapping and impaired gas exchange, making it harder to clear mucus and other secretions, thus increasing the risk of respiratory infections. Option A) Decreased functional cilia is not the correct answer because while cilia function may decline with age, it is not a primary factor contributing to decreased secretion clearance. Cilia play a role in moving mucus out of the airways, but their decline alone does not have as significant an impact as small airway closure. Option B) Decreased force of cough is not the correct answer because while cough strength may diminish with age, it is not the primary reason for decreased secretion clearance. Coughing is a mechanism to clear secretions, but small airway closure has a more direct impact on secretion clearance. Option C) Decreased chest wall compliance is not the correct answer because this factor primarily affects lung expansion and respiratory function but is not directly related to secretion clearance. While decreased chest wall compliance can impact overall lung function, it is not the primary reason for decreased secretion clearance in the respiratory system. Educationally, understanding age-related changes in the respiratory system is crucial for healthcare providers, especially those working with older adults. By recognizing these changes and their implications on respiratory function, providers can implement appropriate interventions to support effective secretion clearance and respiratory health in aging individuals.