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Difficulty: Very hardReduction of Risk Potential

A practical nurse (PN) is performing a 2-hour post-procedure assessment on a client who underwent a left-sided thoracentesis with 1,200 mL of pleural fluid removed. The client's medical history includes hypertension managed with daily metoprolol. The client reports a new, persistent dry cough but denies dyspnea. Current vital signs are: heart rate 86 bpm (baseline 64 bpm), blood pressure 104/66 mm Hg (baseline 142/86 mm Hg), and respiratory rate 18 breaths/min. Which action should the PN take first?

  1. Notify the supervising registered nurse immediately regarding the vital sign trends and the onset of the cough.Answer
  2. B
    Document the vital signs as stable because the heart rate and blood pressure remain within standard adult physiological limits.
  3. C
    Instruct the client to perform deep breathing exercises independently to help suppress the persistent cough.
  4. D
    Assist the client into a flat, supine position to promote venous return and elevate the blood pressure.

Answer

The practical nurse must immediately notify the supervising registered nurse about the vital sign changes and the new cough.
The client is exhibiting early, subtle signs of a severe post-procedure complication, such as a pneumothorax or re-expansion pulmonary edema. The rapid removal of a large volume of pleural fluid (greater than 1,000 mL) significantly increases this risk. A new, persistent dry cough is a key early clinical indicator of these complications. Furthermore, the client's vital signs demonstrate a significant drop in blood pressure and a relative increase in heart rate. Because the client takes metoprolol (a beta-blocker), the heart rate will not elevate as dramatically as expected during hypovolemia or shock, making an increase from 64 to 86 bpm highly concerning. The practical nurse must recognize these borderline changes as signs of clinical deterioration and immediately escalate the situation to the registered nurse.

Step-by-Step Solution

1
Analyze the client's baseline vital signs compared to current readings, noting the pharmacological effect of the client's medication.
The heart rate has increased by 22 bpm and the blood pressure has dropped significantly. Because the client takes metoprolol (a beta-blocker), the normal compensatory tachycardic response to fluid loss or shock is blunted.
Recognizing relative tachycardia in a beta-blocked patient is essential for identifying early hemodynamic instability.
2
Correlate the vital sign changes with the clinical presentation and the specific risks of the recent procedure.
The rapid removal of a large volume of pleural fluid (1,200 mL) combined with a new, persistent cough points to a developing complication such as a pneumothorax or re-expansion pulmonary edema.
A persistent dry cough is a hallmark warning sign of a severe pulmonary complication following a thoracentesis.
3
Determine the appropriate scope of practice and priority nursing action for the practical nurse.
The PN must recognize this as an unstable, potentially life-threatening situation that requires immediate escalation to the registered nurse for further assessment and intervention.
Independent interventions or assuming the findings are benign exceeds the LPN/LVN scope of practice and delays critical medical care.

Key Concept

Early Recognition of Post-Thoracentesis Complications
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Topics

Reduction of Risk Potential

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