ANS: C Show Rationale: A- Stridor is a high-pitched, shrill, harsh sound caused by laryngeal obstruction and can be heard on auscultation over the upper airways or with the naked ear. B- Rhonchi are continuous, low-pitched, coarse sounds often described as having a snoring or moaning quality that occur with partial bronchial obstruction caused by mucus, bronchospasm, foreign bodies, or tumors. D- High pitched crackles are fine, short, interrupted popping sounds best heard on inspiration that occur with problems such as heart failure when air passes through fluid within the alveoli. ANS: C Rationale: A- The statement, "Every client with a laryngectomy is different. It's difficult to say," is an evasive answer and offers no plans for goal setting. B- Initially, the response, "It must be difficult for you, but be patient. These things take time," identifies feelings, but does not answer the client's question. D- Written information can be helpful, but the nurse does not know whether esophageal speech is a good option for this client. Which actions will the nurse take when preparing a client before thoracentesis?The correct answer to today's NCLEX-RN® Question is...
Rationale: During a thoracentesis a needle is inserted into the intercostal space, so the nurse should assist the client to sit at the edge of the bed while leaning forward with their arms supported on a bedside table and a pillow or folded towel.
What should I do before thoracentesis?Before a thoracentesis, a chest ultrasound will be done to identify the exact location of the pleural effusion. An ultrasound is preferred because it is more accurate in determining the location of the effusion and the distance from the skin to the fluid collection than a chest X-ray or physical examination.
How does a nurse prepare a patient for thoracentesis?Asked the patient to remove any clothing, jewelry, or other objects that may interfere with the procedure. The area around the puncture site may be shaved. Vital signs (heart rate, blood pressure, breathing rate, and oxygen level) are to be monitored before the procedure.
What is the procedure for thoracentesis?Thoracentesis is a procedure to remove fluid or air from around the lungs. A needle is put through the chest wall into the pleural space. The pleural space is the thin gap between the pleura of the lung and of the inner chest wall. The pleura is a double layer of membranes that surrounds the lungs.
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Which actions will the nurse take when preparing a client before thoracentesis select all that apply
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