The nurse is preparing a patient for a thoracentesis. Which action is appropriate?

Correct Answer: C

Rationale: The correct answer is C: Position the patient sitting upright and leaning forward on a table. This position allows for easier access to the thoracic cavity and helps prevent potential complications such as pneumothorax. Prone position (A) makes access difficult, NPO for 8 hours (B) is unnecessary for this procedure, and Trendelenburg position (D) can increase the risk of aspiration.

Correct Answer: B

Rationale: The correct answer is B: Oxygen saturation of 89%. A low oxygen saturation level of 89% indicates hypoxemia and requires immediate intervention to prevent complications like tissue damage or organ failure. Oxygen is essential for cellular function, and a saturation below 90% is concerning. Coughing with blood-tinged sputum (A) is common post-bronchoscopy. Hoarseness and sore throat (C) are expected due to the procedure. Mild chest discomfort (D) is also common post-bronchoscopy and may not require immediate intervention.

Correct Answer: C

Rationale: The correct next action is to assess the system for an air leak. This is because continuous bubbling in the water-seal chamber indicates air is escaping from the patient's chest cavity through the tube. By assessing the system for an air leak, the nurse can identify and address the source of the problem. Clamping the chest tube (choice A) can lead to a tension pneumothorax and is not appropriate. Adding more water (choice B) is incorrect as it will not address the underlying issue. Replacing the entire system (choice D) is unnecessary without first identifying the specific problem.

Correct Answer: C

Rationale: The correct answer is C: Assess the system for loose connections or dislodgment. This is the best action because identifying the cause of the air leak is crucial before taking any further steps. Clamping the chest tube (A) can lead to tension pneumothorax. Notifying the healthcare provider (B) is important but does not address the immediate need to assess the system. Increasing suction (D) can worsen the situation if the cause of the air leak is not resolved. Overall, assessing the system first ensures proper management and prevents potential complications.

Correct Answer: B

Rationale: Correct Answer: B - Administer anticoagulant therapy as prescribed. Rationale: 1. Anticoagulant therapy helps prevent further clot formation in the lungs. 2. It helps dissolve existing clots and improve blood flow. 3. This intervention is crucial in managing and treating pulmonary embolism effectively. Summary: - A: Placing the patient in a supine position may worsen the condition by reducing blood flow to the lungs. - C: Deep breathing exercises are beneficial, but anticoagulant therapy takes precedence. - D: Restricting fluid intake is not a priority in the management of a pulmonary embolism.