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Difficulty: Very hardReduction of Risk Potential

A nurse is caring for a client with a history of left-sided heart failure who just underwent a bedside thoracentesis. During the procedure, 1,800 mL1,800\text{ mL} of pleural fluid was rapidly removed. One hour later, the client develops severe dyspnea, a violent cough, and expectorates pink, frothy sputum. The client's vital signs are: blood pressure 88/54 mmHg88/54\text{ mmHg}, heart rate 122 bpm122\text{ bpm}, respiratory rate 32 breaths/min32\text{ breaths/min}, and SpO2SpO_2 86%86\% on a 2 L/min2\text{ L/min} nasal cannula. An arterial blood gas (ABG) analysis reveals:

- pHpH: 7.267.26
- PaCO2PaCO_2: 55 mmHg55\text{ mmHg}
- HCO3−HCO_3^-: 23 mEq/L23\text{ mEq/L}
- PaO2PaO_2: 52 mmHg52\text{ mmHg}

Which of the following actions should the nurse perform FIRST to reduce the client's risk of imminent physiological collapse?

  1. Apply oxygen via a non-rebreather mask and prepare the client for positive pressure ventilation.Answer
  2. B
    Administer a prescribed rapid isotonic intravenous fluid bolus to restore intravascular volume and correct the hypotension.
  3. C
    Initiate a prescribed intravenous sodium bicarbonate infusion to correct the severe uncompensated metabolic acidosis.
  4. D
    Position the client in the lateral decubitus position with the unaffected lung down to optimize ventilation-perfusion matching.

Answer

The correct action is to apply oxygen via a non-rebreather mask and prepare the client for positive pressure ventilation.
The client is exhibiting classic signs of re-expansion pulmonary edema (REPE), a life-threatening complication that can occur when a large volume of pleural fluid (typically greater than 1,500 mL1,500\text{ mL}) is rapidly removed. The rapid expansion of the collapsed lung causes capillary damage and massive fluid shifting into the alveoli, evidenced by severe dyspnea, hypoxia, and pink, frothy sputum. The ABG indicates acute, uncompensated respiratory acidosis (low pHpH, high PaCO2PaCO_2, normal HCO3−HCO_3^-) and severe hypoxemia (PaO2PaO_2 52 mmHg52\text{ mmHg}). The nurse's immediate priority is to address the failing airway and breathing by applying high-flow oxygen via a non-rebreather mask and preparing for positive pressure ventilation (such as CPAP, BiPAP, or endotracheal intubation) to force fluid out of the alveoli and improve gas exchange.

Step-by-Step Solution

1
Analyze the client's clinical presentation post-thoracentesis.
The client has pink, frothy sputum, severe dyspnea, and hypoxia shortly after a large-volume (1,800 mL1,800\text{ mL}) fluid removal.
These are hallmark signs of re-expansion pulmonary edema (REPE), a life-threatening complication.
2
Interpret the arterial blood gas (ABG) values.
The ABG shows a low pHpH (7.267.26), elevated PaCO2PaCO_2 (55 mmHg55\text{ mmHg}), and normal HCO3−HCO_3^- (23 mEq/L23\text{ mEq/L}).
This confirms acute uncompensated respiratory acidosis secondary to massive alveolar flooding, ruling out metabolic causes.
3
Determine the priority physiological need.
The client is in acute respiratory failure, making airway and breathing the immediate priority over circulation.
Although the client is hypotensive, fluid resuscitation is contraindicated in the presence of acute pulmonary edema.
4
Select the most appropriate risk-reduction intervention.
Apply oxygen via a non-rebreather mask and prepare for positive pressure ventilation.
High-flow oxygen and positive pressure are essential to force fluid out of the alveoli, recruit collapsed lung units, and prevent imminent cardiopulmonary arrest.

Key Concept

Re-expansion pulmonary edema (REPE) is a severe complication of large-volume thoracentesis requiring immediate high-flow oxygenation and positive pressure ventilation to prevent fatal cardiopulmonary collapse.
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Topics

Reduction of Risk Potential

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