Nokea
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.
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A healthcare professional is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?
- A. Impulse control difficulty
- B. Poor judgement
- C. Inability to recognize familiar objects
- D. Loss of depth perception
Correct Answer: C
Rationale: Patients who have experienced a left-hemispheric stroke may exhibit symptoms of agnosia, which is the inability to recognize familiar objects or people. This occurs due to damage to the right hemisphere of the brain, which is responsible for visual and spatial perception. Impulse control difficulty, poor judgment, and loss of depth perception are not typically associated with left-hemispheric strokes.
A client experiencing dyspnea will receive continuous oxygen. Which oxygen device should be used to deliver a precise amount of oxygen?
- A. Non-rebreather mask
- B. Venturi mask
- C. Nasal cannula
- D. Simple face mask
Correct Answer: B
Rationale: A Venturi mask is the most appropriate choice for delivering a precise amount of oxygen to a client with dyspnea. Unlike other oxygen delivery devices, the Venturi mask allows for accurate oxygen concentration delivery by controlling the amount of air entrained. This feature is crucial in ensuring the client receives the prescribed oxygen concentration, especially in cases where precise oxygen delivery is required.
A healthcare professional is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the professional recognize?
- A. Confusion
- B. Pale skin
- C. Bradycardia
- D. Hypotension
Correct Answer: B
Rationale: Pale skin is an early manifestation of hypoxemia due to decreased oxygenation of the blood. The skin may appear pale as the body redirects blood flow to vital organs in response to low oxygen levels. Confusion, bradycardia, and hypotension may occur as hypoxemia worsens, but pale skin is one of the initial signs that healthcare professionals should recognize when assessing a client experiencing respiratory distress.
A healthcare provider is preparing to care for a client following chest tube placement. Which of the following items should NOT be available in the client's room?
- A. Oxygen
- B. Sterile water
- C. Enclosed hemostat clamps
- D. Indwelling urinary catheter
Correct Answer: D
Rationale: Following chest tube placement, an indwelling urinary catheter is not typically needed or relevant to the care provided. Chest tube placement is primarily concerned with managing pleural effusion or pneumothorax, and urinary catheterization is not directly related to this procedure. Oxygen, sterile water, and enclosed hemostat clamps are commonly used items in the care of a client with a chest tube in place, to ensure proper oxygenation, maintain drainage system integrity, and manage any bleeding that may occur. Therefore, the indwelling urinary catheter should not be available in the client's room following chest tube placement.
During an assessment, a healthcare provider observes a client with a chest tube and drainage system. What is an expected finding?
- A. Continuous bubbling in the water seal chamber
- B. Gentle constant bubbling in the suction control chamber
- C. Drainage system positioned upright at chest level
- D. Exposed sutures without dressing
Correct Answer: B
Rationale: When assessing a client with a chest tube and drainage system, gentle constant bubbling in the suction control chamber is an expected finding. This indicates that the system is functioning properly. Continuous bubbling in the water seal chamber would suggest an air leak, the drainage system should be positioned upright at chest level to promote proper drainage, and exposed sutures without dressing would be an incorrect finding as they should be covered to prevent infection.