# A nurse is caring for a client with pleural effusion who is scheduled for thoracentesis. Which nursing intervention is the priority before the procedure?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541306  
> language: ko  
> subject: Adult Health

## 문제

A nurse is caring for a client with pleural effusion who is scheduled for thoracentesis. Which nursing intervention is the priority before the procedure?

## 보기

1. Administer prescribed analgesics for pain management
2. Obtain informed consent and verify client understanding of the procedure **✔ 정답**
3. Position the client in high Fowler's position to facilitate breathing
4. Assess baseline vital signs and oxygen saturation levels

**정답: 2**

## 해설

Obtaining informed consent is the priority before any invasive procedure like thoracentesis, as it is a legal and ethical requirement. Other interventions like pain management, positioning, or vital signs assessment are important but secondary to consent.

## 심화 해설

Clinical Judgment
This problem is a priority-setting problem that combines the Recognize Cues and Generate Solutions stages. All options are nursing interventions needed before thoracentesis, but legal and ethical obligations are **absolute prerequisites** for proceeding with the procedure. The patient's condition (progressive dyspnea, chest pain) indicates the urgency of the procedure, but no invasive procedure can begin without proper informed consent. The nurse's role is not simply to obtain a signature, but to verify that the patient understands the purpose, risks, benefits, and alternatives of the procedure (Client Education) and to assess their decision-making capacity.

Memory Tip
The priority before an invasive procedure is **C**onsent first, **C**are second. Remember it as "**I**nformed **C**onsent is the **K**ey."

KR vs US
In Korea, the physician primarily explains and obtains consent, but the nurse plays a supporting role by checking the patient's understanding and asking if they have additional questions. In the US NGN/CJMM, it is standard practice for the nurse to assess the patient's decision-making capacity and confirm their understanding of the explanation, which is emphasized as part of legal responsibility. The consent process is more formal and patient-centered.

## 임상 시나리오

Clinical Practice Guide
Before thoracentesis, the nurse should make the following comprehensive preparations:
1.  Confirm informed consent: Document the signed consent form and the patient's understanding.
2.  Assess baseline status: Measure vital signs, oxygen saturation, breath sounds, and pain level to establish a comparison baseline for after the procedure.
3.  Prepare positioning: Have the patient sit on the edge of the bed with arms and head supported on a support to achieve a comfortable position. This expands the thoracic cavity and assists the practitioner.
4.  Provide psychological support: Explain the procedure and alleviate anxiety.
5.  Prepare necessary supplies: Prepare a sterile puncture set, local anesthetic, culture tubes, etc.

Caution
-   In SATA (Select All That Apply) questions, if asked about the "priority" intervention, obtaining informed consent is the single correct answer.
-   If asked about interventions to perform "immediately before" the procedure, measuring baseline vital signs and changing position may be more appropriate answers. Read the question context accurately.
-   Pain management (option 1) is important, but if the pain before the procedure is not severe, it is a lower priority. Monitoring pain after the procedure may be more important.

## 핵심 개념

- **Thoracentesis** — Thoracentesis. An invasive procedure in which a needle is inserted into the pleural space to remove excess fluid (pleural effusion) or collect a sample.
- **Informed Consent** — Informed consent. The voluntary agreement given by a patient after being fully informed about and understanding the nature, purpose, risks, benefits, and alternatives of a medical procedure. A legal and ethical requirement.
- **Pleural Effusion** — Pleural effusion. A condition where fluid abnormally accumulates in the space between the pleura surrounding the lungs. It can cause dyspnea and chest pain.
- **Dyspnea** — Shortness of breath. A subjective symptom of feeling breathless or having difficulty breathing.
- **Client Education** — Patient education. A nursing process that helps patients understand information about their health condition and treatment, make informed decisions, and effectively perform self-care.

## 같은 주제 문제

- [A nurse is assessing a patient with suspected pleural effusion. Which assessment finding w…](https://mymerci.kr/pages/nclex_q.php?qn_id=541304)
- [A nurse is assessing a patient with suspected pleural effusion. Which assessment finding w…](https://mymerci.kr/pages/nclex_q.php?qn_id=541305)
- [A nurse is caring for a client with pleural effusion who is scheduled for thoracentesis. W…](https://mymerci.kr/pages/nclex_q.php?qn_id=541307)
- [A nurse is caring for a client with pleural effusion who underwent thoracentesis. Which nu…](https://mymerci.kr/pages/nclex_q.php?qn_id=541308)
- [A nurse is caring for a client who underwent thoracentesis for pleural effusion 2 hours ag…](https://mymerci.kr/pages/nclex_q.php?qn_id=541309)
- [A nurse is caring for a 65-year-old patient with congestive heart failure who has develope…](https://mymerci.kr/pages/nclex_q.php?qn_id=541310)
- [A nurse is caring for a 45-year-old client with pleural effusion who is scheduled for thor…](https://mymerci.kr/pages/nclex_q.php?qn_id=541311)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._