Which action should the nurse take to prepare a client with a pleural effusion for a thoracentesis?

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Question 1 of 5

Which action should the nurse take to prepare a client with a pleural effusion for a thoracentesis?

Correct Answer: C

Rationale: The correct action is to position the client sitting up on the side of the bed. This position allows for easier access to the pleural space during the thoracentesis procedure. Sitting up also helps to expand the intercostal spaces, making it easier for the healthcare provider to locate the fluid collection. Choice A is incorrect as fasting is not typically required for a thoracentesis procedure. Choice B is unnecessary as sedation is not routinely used for this procedure. Choice D is incorrect as the amount of pleural fluid to be removed varies and a specific collection device is not always needed. In summary, positioning the client sitting up on the side of the bed is the most appropriate action to prepare for a thoracentesis procedure, as it facilitates access and fluid removal.

Question 2 of 5

The organs of the conducting zone of the respiratory system include all the following EXCEPT:

Correct Answer: D

Rationale: The correct answer is D: alveoli. The conducting zone of the respiratory system consists of structures that conduct air to and from the gas exchange surfaces. Alveoli are the site of gas exchange, not part of the conducting zone. The nose (A), trachea (B), and bronchi (C) are all part of the conducting zone as they help transport air to the lungs. Alveoli are where oxygen and carbon dioxide exchange occurs during respiration.

Question 3 of 5

Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?

Correct Answer: A

Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, harsh sound heard during inspiration or expiration due to airway obstruction. It is a critical sign that requires immediate attention as it indicates a potential blockage in the airway, which can lead to respiratory distress or failure. Explanation of why other choices are incorrect: - B: Occasional pink-tinged sputum may indicate mild bleeding, but it is not an immediate concern post-extubation. - C: A few basilar lung crackles on the right could indicate fluid in the lungs, but it is not as urgent as airway obstruction. - D: A respiratory rate of 24 breaths/min is within the normal range for an adult and does not necessarily indicate an immediate issue post-extubation.

Question 4 of 5

The nurse assesses a male client's respiratory status. Which observation indicates that the client is experiencing difÏculty breathing?

Correct Answer: B

Rationale: The correct answer is B: Use of accessory muscles. This indicates difficulty breathing as the client is struggling to breathe, leading to the recruitment of additional muscles such as neck and chest muscles to aid in respiration. Diaphragmatic breathing (A) is a normal breathing pattern. Pursed-lip breathing (C) is a technique used to improve breathing efficiency. Controlled breathing (D) refers to breathing techniques that help in relaxation but do not necessarily indicate difficulty breathing.

Question 5 of 5

When asked by a tubercular patient how long he will have to take his TB medications, the nurse's best response would be:

Correct Answer: B

Rationale: The correct answer is B. Tuberculosis requires a prolonged treatment duration to ensure complete eradication of the bacterial infection. Typically, TB medications need to be taken for at least 6 to 9 months to prevent relapse or drug resistance. In some cases, especially if drug-resistant strains are involved, treatment can last up to 2 years. Choice A is incorrect because 2 weeks is not a sufficient duration for TB treatment. Choice C is incorrect because TB medications are not usually taken throughout the entire lifespan, but for a specific treatment period. Choice D is incorrect as it does not provide a specific and accurate answer to the patient's query regarding the duration of the treatment.

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