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Difficulty: MediumReduction of Risk Potential

A nurse is receiving a client who just underwent a bedside thoracentesis for a large right-sided pleural effusion. Which of the following nursing actions are essential to monitor and reduce the risk of post-procedure complications? Select all that apply.

  1. Evaluate the client for tracheal deviation toward the unaffected side and sudden onset of dyspnea.Answer
  2. B
    Position the client flat and supine in bed for the first 4 hours to prevent fluid shifts.
  3. Auscultate bilateral breath sounds to detect diminished or absent aeration on the right side.Answer
  4. D
    Delegate the initial post-procedure vital sign measurements to the unlicensed assistive personnel (UAP).
  5. E
    Attribute a narrowing pulse pressure and mild resting tachycardia to expected post-procedure anxiety.
  6. Instruct the client to immediately report any new onset of severe coughing or blood-tinged sputum.Answer

Answer

The essential actions are evaluating for tracheal deviation and dyspnea, auscultating bilateral breath sounds, and instructing the client to report severe coughing or blood-tinged sputum.
Following a thoracentesis, the nurse must prioritize assessments that detect potentially fatal complications such as a tension pneumothorax or hemothorax. Tracheal deviation, sudden dyspnea, absent breath sounds, severe coughing, and hemoptysis are critical indicators of lung puncture or pulmonary hemorrhage. Recognizing these findings immediately reduces the risk of severe physiological injury.

Step-by-Step Solution

1
Identify the primary risks associated with a thoracentesis.
The most significant post-procedure risks include pneumothorax, bleeding (hemothorax), infection, and re-expansion pulmonary edema.
Understanding the anatomical risks (puncture of lung tissue or vessels) directs the nurse's focused assessment.
2
Select interventions that actively monitor for or prevent these specific risks.
Assessing for tracheal deviation, absent breath sounds, and hemoptysis directly monitors for a pneumothorax or internal bleeding.
Prompt recognition of these adverse events allows for life-saving interventions.
3
Eliminate inappropriate or dangerous actions.
Dismissing early signs of shock, placing the patient flat, and delegating the initial critical assessment are eliminated.
These actions increase the client's risk of severe physiological decompensation and violate core safety standards.

Key Concept

Thoracentesis Post-Procedure Monitoring and Risk Reduction
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Topics

Reduction of Risk Potential

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