Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another chest x-ray, you will explain:

Correct Answer: C

Rationale: In this scenario, the correct answer is C) to decongest. The rationale behind this is that after a thoracentesis, where fluid is removed from the pleural space, a chest x-ray may be ordered to assess the re-expansion of the lung and to ensure that there is no fluid accumulation or complications. This helps in monitoring the effectiveness of the procedure and the overall lung health. Option A) to rule out pneumothorax is incorrect because a chest x-ray is typically not needed to diagnose a pneumothorax immediately after a thoracentesis, as this complication would be evident during the procedure itself. Option B) to rule out any possible perforation is incorrect because perforation would typically be suspected during the thoracentesis procedure itself, and immediate intervention would be taken if this were the case. Option D) to rule out any foreign body is incorrect as well because a chest x-ray would not be the primary diagnostic tool for detecting a foreign body in this context; other imaging modalities or procedures would be more appropriate for this purpose. Educationally, understanding the rationale behind post-thoracentesis care and monitoring is crucial for nurses and healthcare providers involved in the management of patients undergoing such procedures. It reinforces the importance of appropriate diagnostic tests and monitoring to ensure patient safety and optimal outcomes.

Correct Answer: C

Rationale: In this situation, the first step should be to report the matter to your supervisor. It is essential to notify the appropriate authority immediately to address the discrepancy in the narcotics cabinet. Choice A is not the first step as reporting to the nursing director should follow after informing the supervisor. Keeping the findings to yourself (Choice B) is not appropriate as it may jeopardize patient safety and is against ethical standards. While finding out which patient received narcotics (Choice D) is important, it is not the immediate action to take in this scenario.

Correct Answer: C

Rationale: In caring for a patient like Conrad with a brain tumor and increased Intracranial Pressure (ICP), providing sensory stimulation (Option C) is the most appropriate intervention to include in the plan to reduce ICP. Sensory stimulation helps to prevent sensory deprivation and promote brain activity without increasing ICP, unlike other interventions. Administering a bowel softener (Option A) may be important for overall patient comfort and preventing straining during bowel movements, but it does not directly address reducing ICP. Positioning Conrad with his head turned toward the side of the tumor (Option B) may increase ICP by potentially obstructing blood flow or causing increased pressure on the tumor. Encouraging coughing and deep breathing (Option D) can also increase ICP due to the increased intrathoracic pressure associated with these actions. Educationally, understanding the rationale behind interventions for patients with increased ICP is crucial for nurses and healthcare providers to ensure optimal patient care and outcomes. By selecting the correct intervention, patient safety and well-being are prioritized while minimizing risks associated with treatments that could potentially worsen the patient's condition.

Correct Answer: C

Rationale: In pharmacology, particularly when administering blood and blood products, assessing baseline vital signs of the client is crucial before the procedure. This step helps the nurse establish a baseline to monitor for any potential adverse reactions or changes in the client's condition during and after transfusion. Option A is incorrect because checking the client's name, identification number, ABO, and RH type is important but is not the first priority before administering blood products. Option B, explaining the procedure to the client, is also important but comes after ensuring the client's vital signs are stable. Checking for the BT order (Option D) is important, but not as critical as assessing the client's vital signs. Educationally, understanding the sequence of steps in preparing for blood transfusion is vital for patient safety. Emphasizing the importance of assessing vital signs before any procedure involving blood products helps students grasp the significance of monitoring a patient's condition and being proactive in preventing complications. This rationale reinforces the prioritization of patient safety and the importance of thorough assessment in clinical practice.

Correct Answer: D

Rationale: After a total thyroidectomy, it is crucial to support the patient's head and neck with pillows and sandbags. This positioning helps to prevent strain on the neck and minimizes the risk of injury or complications postoperatively. Supporting the head and neck also promotes proper alignment and assists in maintaining a neutral position, which is essential for optimal healing and comfort. Option A, placing pillows under the patient's shoulders, does not directly address the need to support the head and neck, which is the primary concern after a thyroidectomy. Option B, raising the knee-gatch to 30 degrees, is unrelated to the surgical procedure and does not provide any benefit in terms of postoperative care. Option C, keeping the patient in a high-Fowler's position, may be appropriate for respiratory support in certain situations but is not specifically indicated after a thyroidectomy. In an educational context, understanding the rationale behind positioning interventions after surgical procedures is crucial for nursing practice. It ensures that nurses can provide safe and effective care to promote patient recovery and prevent complications. By grasping the significance of proper head and neck support after a thyroidectomy, nurses can contribute to positive patient outcomes and overall quality of care.