a nurse is caring for a client who is scheduled to undergo a thoracentesis which intervention should the nurse complete prior to procedure

ATI RN

ATI Medical Surgical Proctored Exam

1. Prior to a thoracentesis, what intervention should the nurse complete?

A. Measure oxygen saturation before and after the procedure.
B. Verify that the client has given informed consent.
C. Explain the procedure briefly to the client and their family.
D. Ensure informed consent has been obtained from the client.

Correct answer: D

Rationale: Before a thoracentesis procedure, it is crucial to ensure that the client has given informed consent. This process involves explaining the procedure, its risks, benefits, and alternatives to the client, and obtaining their signature on the consent form. Verifying informed consent is a vital legal and ethical step to protect the client's autonomy and ensure they have made an informed decision about the procedure.

2. How does the pain of a myocardial infarction (MI) differ from stable angina?

A. Accompanied by shortness of breath
B. Feelings of fear or anxiety
C. Lasts about 3-5 minutes
D. Relieved by taking nitroglycerin

Correct answer: A

Rationale: The pain of an MI is often accompanied by shortness of breath and feelings of fear or anxiety. It typically lasts longer than 15 minutes and is not relieved by nitroglycerin. Unlike stable angina, the pain of an MI occurs without a known cause such as exertion.

3. A client has a pulmonary embolism & is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?

A. Breathing so rapidly interferes with oxygenation.
B. Maybe the client has respiratory distress syndrome.
C. The blood clot interferes with perfusion in the lungs.
D. The client needs immediate intubation & mechanical ventilation.

Correct answer: C

Rationale: A large blood clot in the lungs will significantly impair gas exchange & oxygenation. Unless the clot is dissolved, this process will continue unabated.

4. A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory capabilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?

A. 1530 (3:30 PM)
B. 1600 (4:00 PM)
C. 1630 (4:30 PM)
D. 1700 (5:00 PM)

Correct answer: C

Rationale: The Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of the diagnosis of myocardial infarction. Since the client presented at 1500 (3:00 PM), the percutaneous coronary intervention should be performed no later than 1630 (4:30 PM), to adhere to the 90-minute timeline for optimal outcomes.

5. A healthcare professional is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the healthcare professional expect?

A. Bradycardia
B. Bradypnea
C. Lethargy
D. Intercostal retractions

Correct answer: D

Rationale: Postoperative atelectasis can lead to hypoxia, which causes respiratory distress. Intercostal retractions, where the muscles between the ribs pull inward during inspiration, are a common sign of respiratory distress in a client with atelectasis. Bradycardia (slow heart rate), Bradypnea (slow breathing rate), and lethargy are not typically associated with atelectasis and hypoxia.