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Difficulty: MediumReduction of Risk Potential

During a bedside assessment, a licensed practical nurse evaluates an adult client who underwent a right-sided thoracentesis earlier in the shift. The client suddenly reports a sharp, localized chest pain and exhibits a dry, hacking cough. Current vital signs reveal a respiratory rate of 26 breaths per minute, a heart rate of 114 beats per minute, and an oxygen saturation of 90% on room air. Which action should the nurse prioritize?

  1. Alert the supervising registered nurse immediately about the assessment findings.Answer
  2. B
    Provide the prescribed PRN oral analgesic to manage the localized chest pain.
  3. C
    Instruct the client to take deep breaths using an incentive spirometer.
  4. D
    Initiate an order for a stat chest radiograph to evaluate for a pneumothorax.

Answer

Alert the supervising registered nurse immediately about the assessment findings.
The correct action acknowledges that the client is displaying critical signs of a pneumothorax (hypoxia, tachypnea, tachycardia, sharp pain), a primary and severe complication following a thoracentesis. In the practical nurse's scope of practice, recognizing sudden respiratory deterioration and immediately escalating the findings to the registered nurse or healthcare provider is the essential action to reduce risk and ensure client safety.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
Tachycardia, tachypnea, hypoxia, sharp chest pain, and a dry cough following a thoracentesis strongly suggest a developing pneumothorax.
Identifying patterns of symptoms is required to recognize severe procedural complications early.
2
Determine the priority framework.
Airway and Breathing are actively compromised, requiring immediate medical intervention.
ABC (Airway, Breathing, Circulation) principles dictate that acute respiratory compromise takes precedence over pain management or routine postoperative care.
3
Evaluate the practical nurse's scope of practice for the required intervention.
The practical nurse must escalate these emergent assessment findings to the RN or healthcare provider.
Practical nurses cannot independently prescribe medications or order diagnostic imaging, making prompt escalation the safest and most legally sound action.

Key Concept

Reduction of Risk Potential: Recognizing Complications of Diagnostic Procedures
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Topics

Reduction of Risk Potential

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