During a thoracentesis, a needle is inserted into the pleural space to remove fluid for diagnostic
or therapeutic purposes. Before the procedure, the nurse places the client in an upright sitting
position on the side of the bed, leaning forward over the bedside table, with arms supported on
pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural
space through the intercostal spaces, and promotes client comfort.
,(Option 1) The fetal position is appropriate for a client having a lumbar puncture, not a
thoracentesis.
(Option 2) If unable to sit, the client can be positioned lying on the unaffected, not affected,
side.
(Option 3) Prone position is not used for this procedure, is uncomfortable, and would make it
more difficult for a client with dyspnea to breathe.
Educational objective:
Before a thoracentesis, the nurse places the client in an upright sitting position on the side of the
bed, leaning forward over the bedside table, with arms supported on pillows. This position
ensures that the diaphragm is dependent, facilitates access to the pleural space through the
intercostal spaces, and promotes client comfort.
,A central line or central venous catheter (CVC) is inserted by the health care provider in a
"central" vein (eg, subclavian, internal jugular, femoral) and is used to administer fluids,
medications, and parenteral nutrition and for hemodynamic monitoring.
Proper hand hygiene should be performed when caring for a CVC to prevent infection, and
nonsterile gloves should be worn to protect the nurse from blood or body fluids at the port site
as one or more lumens are often used to draw blood (Option 3).
The Centers for Disease Control and Prevention recommend that catheter hubs always be
handled aseptically to prevent catheter-associated infections. The hubs should be disinfected
with a hospital-approved antiseptic (eg, 70% alcohol sterile pads; > 0.5% chlorhexidine with
alcohol; 10% povidone-iodine). Always allow the antiseptic to dry before using the hub/port
(Option 4).
, The nurse would expect to hear a murmur with an atrial septal defect. This defect is an
abnormal opening between the right and left atria, allowing blood from the higher pressure left
atrium to flow into the lower pressure right atrium. The back-and-forth flow of blood between
the 2 chambers causes a vibration that is heard as a murmur on auscultation. ASD has a
characteristic systolic murmur with a fixed split second heart sound. Some clients may also
have a diastolic murmur.
(Option 1) Muffled heart tones are not typical in ASD. Muffled heart tones that are heard
postsurgical intervention are concerning for cardiac tamponade.
(Option 3) Atrial and ventricular septal defects are acyanotic congenital heart defects because
the blood from the high pressure left side (oxygenated blood) goes to the low pressure right side.
(Option 4) Weak lower and strong upper extremity pulses are present in coarctation of the aorta.
Educational objective:
In a child with atrial septal defect, the nurse would expect to hear a heart murmur on auscultation
of heart sounds.
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or therapeutic purposes. Before the procedure, the nurse places the client in an upright sitting
position on the side of the bed, leaning forward over the bedside table, with arms supported on
pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural
space through the intercostal spaces, and promotes client comfort.
,(Option 1) The fetal position is appropriate for a client having a lumbar puncture, not a
thoracentesis.
(Option 2) If unable to sit, the client can be positioned lying on the unaffected, not affected,
side.
(Option 3) Prone position is not used for this procedure, is uncomfortable, and would make it
more difficult for a client with dyspnea to breathe.
Educational objective:
Before a thoracentesis, the nurse places the client in an upright sitting position on the side of the
bed, leaning forward over the bedside table, with arms supported on pillows. This position
ensures that the diaphragm is dependent, facilitates access to the pleural space through the
intercostal spaces, and promotes client comfort.
,A central line or central venous catheter (CVC) is inserted by the health care provider in a
"central" vein (eg, subclavian, internal jugular, femoral) and is used to administer fluids,
medications, and parenteral nutrition and for hemodynamic monitoring.
Proper hand hygiene should be performed when caring for a CVC to prevent infection, and
nonsterile gloves should be worn to protect the nurse from blood or body fluids at the port site
as one or more lumens are often used to draw blood (Option 3).
The Centers for Disease Control and Prevention recommend that catheter hubs always be
handled aseptically to prevent catheter-associated infections. The hubs should be disinfected
with a hospital-approved antiseptic (eg, 70% alcohol sterile pads; > 0.5% chlorhexidine with
alcohol; 10% povidone-iodine). Always allow the antiseptic to dry before using the hub/port
(Option 4).
, The nurse would expect to hear a murmur with an atrial septal defect. This defect is an
abnormal opening between the right and left atria, allowing blood from the higher pressure left
atrium to flow into the lower pressure right atrium. The back-and-forth flow of blood between
the 2 chambers causes a vibration that is heard as a murmur on auscultation. ASD has a
characteristic systolic murmur with a fixed split second heart sound. Some clients may also
have a diastolic murmur.
(Option 1) Muffled heart tones are not typical in ASD. Muffled heart tones that are heard
postsurgical intervention are concerning for cardiac tamponade.
(Option 3) Atrial and ventricular septal defects are acyanotic congenital heart defects because
the blood from the high pressure left side (oxygenated blood) goes to the low pressure right side.
(Option 4) Weak lower and strong upper extremity pulses are present in coarctation of the aorta.
Educational objective:
In a child with atrial septal defect, the nurse would expect to hear a heart murmur on auscultation
of heart sounds.
Copyright © UWorld. All rights reserved.
