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. A healthcare professional is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCO2 32 mm Hg, and HCO3 22 mm Hg. The healthcare professional should recognize that the client is experiencing which of the following acid-base imbalances?

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

Correct answer: B

Rationale: The ABG results show a high pH (alkalosis) along with low PaCO2 and normal HCO3 levels, indicating respiratory alkalosis. In this condition, there is excessive loss of carbon dioxide (as seen by the low PaCO2) leading to a decrease in carbonic acid concentration and subsequent increase in pH. Metabolic acidosis or alkalosis would involve primary changes in bicarbonate levels, which are not predominant in this case.

3. Which of the following is not a cause of tachycardia?

A. Fever
B. Exercise
C. Sympathetic nervous system stimulation
D. Parasympathetic nervous system stimulation

Correct answer: D

Rationale: Tachycardia is an increased heart rate, and it can be caused by various factors such as fever, exercise, and sympathetic nervous system stimulation, all of which tend to increase heart rate. However, parasympathetic nervous system stimulation typically slows the heart rate, making it the exception among the choices provided. Thus, parasympathetic nervous system stimulation is not a cause of tachycardia.

4. Which deficiency is most commonly seen in individuals with alcohol use disorder?

A. Thiamine
B. Riboflavin
C. Pyridoxine
D. Pantothenic acid

Correct answer: A

Rationale: Thiamine deficiency, also known as Vitamin B1 deficiency, is the most common vitamin deficiency seen in individuals with alcohol use disorder. Chronic alcohol consumption can lead to decreased thiamine absorption and utilization, as well as poor dietary intake. Thiamine deficiency can result in serious neurological complications, such as Wernicke-Korsakoff syndrome, making it essential to address thiamine supplementation in individuals with alcohol use disorder.

5. What is the appropriate needle size for insulin injection?

A. 18G, 1 ½” long
B. 22G, 1” long
C. 22G, 1 ½” long
D. 25G, 5/8” long

Correct answer: D

Rationale: The appropriate needle size for insulin injection is 25G, 5/8” long. This size allows for accurate and comfortable insulin administration in subcutaneous tissue.