A nurse is assisting a provider with a thoracentesis for a client who is experiencing respiratory distress. Which of the following actions should the nurse take?
Explanation & Rationale
A. Instruct the client to remain flat in bed for 4 to 6 hr after the procedure: Clients are usually positioned sitting upright or leaning forward during thoracentesis, and remaining flat for several hours afterward is not required. Proper positioning after the procedure is typically for comfort and monitoring, not strict bed rest. B. Set up the equipment using clean technique: Thoracentesis is an invasive procedure that requires strict aseptic technique, not just clean technique, to prevent infection and contamination of the pleural space. Using only clean technique would increase the risk of complications. C. Prepare the client for a chest x-ray following the procedure: A post-procedure chest x-ray is recommended to check for complications such as pneumothorax or lung collapse. This imaging ensures that any adverse effects are identified promptly and managed appropriately. D. Insert an indwelling urinary catheter and record the client's output: Inserting a urinary catheter is not part of standard thoracentesis care unless the client has unrelated urinary needs. It does not contribute to the safety or effectiveness of the thoracentesis procedure.