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. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping, and muscle weakness. These symptoms probably indicate that the patient is experiencing:

A. Hypokalemia
B. Hyperkalemia
C. Anorexia
D. Dysphagia

Correct answer: A

Rationale: The symptoms of fatigue, muscle cramping, and muscle weakness in a patient after starting furosemide therapy are indicative of hypokalemia. Furosemide is a loop diuretic that can lead to potassium depletion, causing hypokalemia. Hypokalemia can manifest with muscle weakness, cramps, and fatigue due to alterations in neuromuscular function and decreased ATP production.

3. What is the best description of Back Care?

A. Caring for the back by means of massage
B. Washing the back
C. Applying a cold compress to the back
D. Applying a hot compress to the back

Correct answer: A

Rationale: The correct answer is A: Caring for the back by means of massage. Back Care involves activities like massage, exercises, maintaining proper posture, and using ergonomic practices to keep the spine healthy and prevent injuries. While washing the back is a hygiene practice, applying cold or hot compresses may provide relief for back pain but do not encompass the comprehensive approach of back care like massage does.

4. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?

A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
C. A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
D. A client who delivered precipitously 36 hr ago and has a second-degree perineal laceration

Correct answer: D

Rationale: The most appropriate client to recommend for discharge following a local disaster in the postpartum unit is the one who delivered precipitously 36 hours ago and has a second-degree perineal laceration. This client's condition is stable enough for discharge, and the timing and extent of the perineal laceration are within expectations for a safe discharge. Clients with conditions such as preeclampsia, recent emergency cesarean birth, or recent administration of packed RBCs for postpartum hemorrhage require further monitoring and care before being considered for discharge.

5. What do high-pitched gurgles heard over the right lower quadrant indicate?

A. Increased bowel motility
B. Decreased bowel motility
C. Normal bowel sounds
D. Abdominal cramping

Correct answer: C

Rationale: High-pitched gurgles heard over the right lower quadrant indicate normal bowel sounds. Bowel sounds can vary in pitch, and high-pitched gurgles are considered normal and indicate the presence of active peristalsis in the intestines.