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. What is the most common injury among elderly persons?

A. Atherosclerotic changes in the blood vessels
B. Increased incidence of gallbladder disease
C. Urinary Tract Infection
D. Hip fracture

Correct answer: D

Rationale: Hip fracture is the most common injury among elderly persons. As people age, their bones become more fragile, making them more susceptible to hip fractures, often resulting from falls. These fractures can significantly impact an elderly person's quality of life and mobility, making them a significant concern in geriatric care.

3. When is additional Vitamin C not required?

A. Infancy
B. Young adulthood
C. Childhood
D. Pregnancy

Correct answer: B

Rationale: Vitamin C requirements are increased during infancy, childhood, and pregnancy due to growth and development. However, during young adulthood, the body generally requires a consistent amount of Vitamin C as it is not undergoing rapid growth or physiological changes that necessitate an increase in Vitamin C intake.

4. How can preserving skin integrity impact the circular chain of infection?

A. Host
B. Reservoir
C. Mode of transmission
D. Portal of entry

Correct answer: D

Rationale: Preserving skin integrity plays a key role in breaking the chain of infection by eliminating the portal of entry for pathogens. When the skin is intact, it acts as a natural barrier that prevents pathogens from entering the body. By maintaining skin integrity through proper hygiene and wound care, the risk of infection is significantly reduced, disrupting the cycle of infection transmission.

5. When a family of an accident victim, who has been declared brain-dead, appears open to organ donation, what should the nurse do?

A. Discourage them from deciding until their grief has eased
B. Listen to their concerns and answer their questions truthfully
C. Urge them to immediately sign the consent form
D. Inform them that the body will not be available for a wake or funeral

Correct answer: B

Rationale: In situations involving potential organ donation, the nurse's role is to provide support, listen to the family's concerns, and answer their questions truthfully. By doing so, the nurse can help facilitate an informed and respectful decision-making process for the grieving family.