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
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Nursing Elites

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ATI Fundamentals

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

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. Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions?

Correct answer: D

Rationale: The correct conclusion drawn from the study is that side rails serve as a reminder to the patient not to get out of bed rather than being a fail-proof preventive measure against falls. While they may not entirely prevent falls, they play a role in prompting the patient to be cautious when moving.

3. For abdominal inspection, in which of the following positions should a patient be placed?

Correct answer: C

Rationale: The supine position is ideal for abdominal inspection as it allows the healthcare provider to easily access and examine the abdomen. In the supine position, the patient lies flat on their back with arms at their sides, providing a clear view and access to the abdominal area for inspection.

4. How many ounces are in 1 cup?

Correct answer: A

Rationale: 1 cup is equivalent to 8 ounces. This conversion is commonly used in cooking and baking recipes, where precise measurements are crucial for the successful outcome of dishes. Knowing this conversion helps ensure that ingredients are accurately measured and the recipe turns out as intended. Choices B, C, and D are incorrect because they do not reflect the correct conversion between cups and ounces. 80, 800, and 8000 ounces are significantly higher quantities than what is found in 1 cup, which is 8 ounces.

5. A healthcare professional is assessing a client who has a pulmonary embolism. Which of the following information should the healthcare professional not expect to find?

Correct answer: A

Rationale: In a client with a pulmonary embolism, bradypnea, which is abnormally slow breathing, is not an expected finding. Pulmonary embolism typically presents with tachypnea (rapid breathing) due to the body's compensatory mechanism to increase oxygen levels. Pleural friction rub, petechiae, and tachycardia are commonly associated with a pulmonary embolism due to the impaired oxygenation and increased workload on the heart. Therefore, the healthcare professional should not expect to find bradypnea during the assessment of a client with a pulmonary embolism.

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