A nurse is assisting a healthcare provider with a bedside thoracentesis for a client diagnosed with a right-sided pleural effusion. Which nursing actions are appropriate to reduce the risk of procedural complications? Select all that apply.
- Ensure the client is positioned upright, leaning forward with arms resting on an overbed table.Answer
- Instruct the client to refrain from coughing, taking deep breaths, or talking during needle insertion.Answer
- CPosition the client flat on the affected right side if they become too fatigued to maintain an upright posture.
- Verify that the client's most recent coagulation studies and platelet count have been evaluated prior to the procedure.Answer
- EDelegate the continuous monitoring of the client's oxygen saturation to an unlicensed assistive personnel (UAP) during fluid drainage.
- FPrioritize the assessment of bilateral pedal pulses immediately following the removal of the needle.
Answer
The correct actions include positioning the client upright and leaning forward, instructing them to avoid coughing or deep breathing, and verifying coagulation studies prior to the procedure.
To reduce the risk of potential complications during a thoracentesis, the nurse must ensure interventions promote safe access to the pleural space, prevent bleeding, and monitor for respiratory distress. Positioning the client upright and leaning forward widens the intercostal spaces. Instructing the client to avoid moving or coughing prevents the needle from puncturing the lung. Verifying coagulation studies minimizes the risk of severe bleeding.
Step-by-Step Solution
Key Concept
Thoracentesis Risk Reduction and Safety