The nurse assesses a patient with a pleural effusion. Which action should the nurse take to prepare the patient for thoracentesis?

Correct Answer: B

Rationale: The correct answer is B because positioning the patient sitting up on the side of the bed allows for better access to the thoracic cavity during thoracentesis. This position helps to maximize lung expansion, making it easier for the healthcare provider to access the pleural effusion. Starting a peripheral IV line to administer sedatives (Choice A) is not necessary for thoracentesis preparation. Obtaining a collection device to hold 3 liters of pleural fluid (Choice C) is not a necessary step for preparing the patient for the procedure. Reminding the patient not to eat or drink for 6 hours (Choice D) is not a standard requirement for thoracentesis preparation.

Correct Answer: B

Rationale: The correct next step is to schedule a chest x-ray to evaluate for active tuberculosis. A positive Mantoux test indicates exposure to the tuberculosis bacteria but doesn't confirm active disease. A chest x-ray helps determine if there is active infection in the lungs. Starting four-drug therapy for tuberculosis (A) is premature without confirming active disease. Repeating the Mantoux test (C) is unnecessary as it won't differentiate between latent and active infection. Administering the BCG vaccine (D) is not indicated in this case as the patient already has a positive Mantoux test.

Correct Answer: A

Rationale: The correct answer is A because maintaining oxygen saturation above 90% is essential for patients with COPD to prevent further respiratory complications. Oxygen therapy helps improve oxygen levels in the blood, reducing the workload on the heart and improving overall oxygen delivery to tissues. Administering oxygen is the immediate intervention needed to improve the patient's oxygen saturation. Option B is incorrect as deep breathing exercises alone may not be sufficient to increase oxygen levels in the blood significantly. Option C is incorrect because notifying the healthcare provider is not the immediate action needed to address the low oxygen saturation. Option D is incorrect as monitoring respiratory rate alone does not address the immediate need to improve oxygen saturation levels.

Correct Answer: A

Rationale: The correct answer is A: Performing oral care with chlorhexidine. This action is effective in preventing VAP by reducing the bacterial load in the oral cavity, which can decrease the risk of aspiration of pathogens into the lungs. Chlorhexidine has antimicrobial properties that help to kill or inhibit the growth of bacteria. Regular oral care can help maintain oral hygiene and prevent colonization of pathogens. Choice B, administering antibiotics prophylactically, is not recommended as routine prophylactic use of antibiotics can lead to antibiotic resistance and disrupt the normal flora, potentially causing more harm than good. Choice C, suctioning the airway every hour, is important for maintaining airway patency but is not the most effective action for preventing VAP. Over-suctioning can irritate the airway and increase the risk of infection. Choice D, keeping the patient sedated at all times, is not a recommended practice as it can lead to complications such as ventilator-associated pneumonia. Sedation can impair the

Correct Answer: B

Rationale: The correct answer is B because an oxygen saturation of 88% indicates severe hypoxemia, requiring immediate intervention to prevent tissue damage. Oxygen therapy is crucial to improve oxygenation. Choice A is not as urgent as hypoxemia. Choice C indicates fluid in the lungs but does not require immediate action. Choice D is within the normal range for respiratory rate.