A patient with pleural effusion is scheduled for a thoracentesis. What is the nurse's role during the procedure?

Correct Answer: D

Rationale: The correct answer is D because providing emotional support and monitoring vital signs are essential roles for the nurse during a thoracentesis procedure. Emotional support helps to reduce anxiety and promote patient comfort. Monitoring vital signs ensures patient safety and early detection of any complications. Choice A (monitor oxygen saturation continuously) is not typically necessary during a thoracentesis unless the patient is at high risk for respiratory compromise. Choice B (instruct the patient to hold their breath) is incorrect as the patient is usually instructed to breathe normally or take shallow breaths during the procedure to minimize movement. Choice C (position the patient on the affected side) is also incorrect as the patient is typically positioned sitting upright or slightly leaning forward to facilitate access to the pleural space.

Correct Answer: A

Rationale: The correct answer is A: Performing oral care with chlorhexidine. This intervention is most effective for preventing VAP because it helps reduce the colonization of pathogenic bacteria in the oral cavity, which can be aspirated into the lungs. Chlorhexidine is an antiseptic agent that can effectively reduce the risk of developing pneumonia. Summary of other choices: B: Changing ventilator tubing every shift - While maintaining clean ventilator tubing is important for infection prevention, it is not the most effective intervention for preventing VAP. C: Suctioning the patient hourly - Frequent suctioning may be necessary for airway clearance, but it is not specifically targeted at preventing VAP. D: Keeping the patient sedated continuously - Continuous sedation may lead to complications such as prolonged ventilation and increased risk of pneumonia. It is not a recommended strategy for preventing VAP.

Correct Answer: A

Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, noisy breathing sound typically heard on inspiration, indicating upper airway obstruction. This finding requires immediate intervention as it can lead to airway compromise and respiratory distress. Explanation for why other choices are incorrect: B: Cough productive of yellow sputum may indicate a respiratory infection but does not necessarily require immediate intervention. C: Oxygen saturation of 92% on 2 L/min oxygen is concerning but not immediately life-threatening. It may require adjustment of oxygen therapy. D: Respiratory rate of 20 breaths per minute falls within the normal range and does not indicate immediate intervention is needed.

Correct Answer: C

Rationale: Rationale: Choice C is correct because hand washing should be performed not just before entering the room but also immediately upon leaving it to prevent the spread of TB. Hand hygiene is crucial in infection control. Choices A, B, and D are incorrect because offering a tissue, wearing a surgical mask, and bringing a snack do not pose a risk of spreading TB and are appropriate actions in caring for a patient with active TB.

Correct Answer: B

Rationale: The correct answer is B: Administer prophylactic antibiotics. This intervention helps prevent infection in the patient undergoing chemotherapy by targeting potential pathogens before they cause harm. Chemotherapy can weaken the immune system, making patients more susceptible to infections. Providing a mask (choice A) may help reduce exposure but does not directly address preventing infection. Repositioning the patient (choice C) is important for preventing complications like pressure ulcers but does not specifically target infection prevention. Performing a sputum culture (choice D) is useful for diagnosing respiratory infections but does not focus on preventing infections proactively. Administering prophylactic antibiotics is a targeted approach to reducing the risk of infection in immunocompromised patients.