Following a therapeutic right-sided thoracentesis to relieve a pleural effusion, a client on the medical-surgical unit suddenly exhibits acute agitation, tachypnea, and sharp right-sided chest pain. To mitigate the risk of severe physiological compromise, which actions must the nurse perform immediately? (Select all that apply.)
- Place the client in an upright, seated posture to optimize respiratory mechanics.Answer
- BTransition the client into a flat, supine position to stabilize the thoracic cavity.
- Alert the rapid response team and the primary healthcare provider.Answer
- DDelay the administration of supplemental oxygen until an arterial blood gas sample is drawn.
- Coordinate with the radiology department for a stat portable chest x-ray.Answer
- FAdminister the prescribed as-needed intravenous opioid analgesic before assessing oxygenation.
Answer
The correct actions are to place the client in an upright posture, alert the rapid response team, and coordinate a stat portable chest x-ray.
The client's presentation of acute agitation, tachypnea, and sharp chest pain following a thoracentesis is highly suspicious for a pneumothorax, a potentially life-threatening complication. Immediate risk reduction involves supporting the airway and breathing by placing the client in an upright position. Because this is a medical emergency, the nurse must activate the rapid response team to bring advanced critical care support to the bedside. Additionally, coordinating a stat portable chest x-ray is essential to confirm the diagnosis and guide definitive life-saving interventions, such as chest tube insertion.
Step-by-Step Solution
Key Concept
Post-thoracentesis complications and physiological risk reduction.