A licensed practical nurse (LPN) is assisting a healthcare provider with a bedside thoracentesis for a client who has a pleural effusion. In what order should the LPN perform the following actions to reduce the client's risk of potential complications? (Arrange the steps from first to last.)
- 1Verify the client's identity and ensure the informed consent form is signed.
- 2Position the client sitting upright on the edge of the bed, leaning over an overbed table.
- 3Instruct the client to remain completely still and refrain from coughing or deep breathing.
- 4Apply a sterile dressing to the puncture site immediately after the needle is withdrawn.
- 5Auscultate bilateral breath sounds and monitor the client's respiratory rate.
Answer
The correct sequence is: Verify identity and consent, position the client upright over a table, instruct the client to remain still, apply a sterile dressing, and finally auscultate breath sounds.
To reduce the risk of complications during a thoracentesis, the practical nurse must follow a logical sequence from pre-procedure preparation to post-procedure monitoring. First, safety protocols require verifying identity and informed consent. Next, optimal positioning is required to safely access the pleural space. Once positioned, instructing the client to remain still prevents accidental lung puncture during the procedure. Immediately after the procedure, a sterile dressing prevents air entry and infection. Finally, the nurse monitors respiratory status to detect complications such as a pneumothorax.
Step-by-Step Solution
Key Concept
Prioritizing nursing actions before, during, and after an invasive procedure to minimize the risk of complications such as organ puncture or pneumothorax.