a nurse is caring for a client who is scheduled for a thoracentesis prior to the procedure which of the following actions should the nurse take

ATI RN

ATI Fundamentals

1. Prior to a thoracentesis, which of the following actions should the nurse take?

A. Position the client in an upright position, leaning over the bedside table.
B. Explain the procedure.
C. Obtain ABGs.
D. Administer benzocaine spray.

Correct answer: A

Rationale: Positioning the client in an upright position, leaning over the bedside table helps to facilitate access to the thoracic cavity during the thoracentesis procedure. This position allows for easier identification and access to the insertion site. Explaining the procedure to the client is important, but positioning is the priority. Obtaining ABGs is not directly related to the thoracentesis procedure. Administering benzocaine spray is not a standard practice before a thoracentesis.

2. Which of the following substances increase the amount of urine produced?

A. Caffeine-containing drinks, such as coffee and cola
B. Beets
C. Urinary analgesics
D. Kaolin with pectin (Kaopectate)

Correct answer: A

Rationale: Caffeine is a diuretic, which means it increases urine production by promoting the excretion of water from the body through the kidneys. Therefore, substances like caffeine-containing drinks, such as coffee and cola, can lead to an increase in the amount of urine produced.

3. A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?

A. Store the glasses in a labeled case.
B. Clean the glasses with hot water
C. Clean the glasses with a paper towel.
D. Store the glasses on the bedside table.

Correct answer: A

Rationale: It is essential for the nurse to store the client's glasses in a labeled case to ensure they are kept safe and protected from damage. Storing them in a case helps prevent scratches, breakage, or misplacement. This practice promotes proper eyewear hygiene and ensures the client has their glasses readily available when needed. Cleaning the glasses with hot water or a paper towel can potentially damage the lenses or frames. Storing the glasses on the bedside table increases the risk of misplacement or damage.

4. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?

A. Less than 30 ml/hour
B. 64 ml in 2 hours
C. 90 ml in 3 hours
D. 125 ml in 4 hours

Correct answer: A

Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.

5. What is the abbreviation for micro drop?

A. µgtt
B. gtt
C. mdr
D. mgts

Correct answer: A

Rationale: The correct abbreviation for micro drop is 'µgtt,' where the symbol 'µ' represents micro and 'gtt' stands for drop. Choice B, 'gtt,' is the abbreviation for drop, not specifically for micro drop. Choice C, 'mdr,' and Choice D, 'mgts,' are not standard abbreviations for micro drop and are incorrect.