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Difficulty: MediumReduction of Risk Potential

A 68-year-old client is being monitored in the progressive care unit two hours after undergoing a bedside left-sided thoracentesis for a pleural effusion. The client suddenly becomes restless, diaphoretic, and has a respiratory rate of 34 breaths/min. The nurse observes diminished breath sounds on the left side and asymmetrical chest expansion. An arterial blood gas (ABG) reveals a pH of 7.49, PaCO2 of 29 mm Hg, PaO2 of 56 mm Hg, and HCO3 of 23 mEq/L. Which action should the nurse implement first to reduce the risk of severe physiological decompensation?

  1. Apply high-flow supplemental oxygen and immediately notify the rapid response team for a suspected pneumothorax.Answer
  2. B
    Coach the client to take slow, shallow breaths to reverse the acute respiratory alkalosis indicated by the blood gas results.
  3. C
    Assist the client into a flat, left lateral position to splint the puncture site and increase venous return to the heart.
  4. D
    Firmly palpate the upper left abdominal quadrant before auscultating bowel sounds to assess for an accidental splenic puncture.

Answer

Apply high-flow supplemental oxygen and immediately notify the rapid response team for a suspected pneumothorax.
The client is exhibiting classic signs of an acute pneumothorax, a known high-risk complication of a thoracentesis. The asymmetrical chest expansion, diminished breath sounds, severe hypoxemia, and compensatory tachypnea require immediate escalation to a rapid response team and high-flow oxygen administration to prevent impending hemodynamic collapse.

Step-by-Step Solution

1
Analyze the client's clinical presentation and the diagnostic ABG data.
The client exhibits signs of a left-sided pneumothorax (diminished breath sounds, asymmetric chest expansion, restlessness). The ABG shows uncompensated respiratory alkalosis driven by critical hypoxemia (PaO2 56 mm Hg).
A thoracentesis carries a significant risk of puncturing the visceral pleura, leading to air entering the pleural space.
2
Determine the priority intervention using the ABC (Airway, Breathing, Circulation) framework.
The client has an acute, life-threatening breathing and oxygenation deficit that takes absolute precedence over other assessments.
Immediate oxygenation and advanced medical intervention are required to prevent the development of a tension pneumothorax and subsequent cardiopulmonary arrest.
3
Select the nursing action that directly mitigates the physiological threat.
Applying high-flow oxygen and activating the rapid response team is the safest and most urgent intervention.
This ensures immediate life-saving support and prepares the team for potential emergency chest tube insertion.

Key Concept

Post-procedure complication recognition and prioritization (Airway, Breathing, Circulation)
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Topics

Reduction of Risk Potential

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