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Difficulty: MediumReduction of Risk Potential

A 64-year-old client is being monitored on the medical-surgical unit 2 hours after a flexible bronchoscopy with transbronchial biopsy. Which assessment findings indicate a developing physiological complication that requires immediate nursing intervention? Select all that apply.

  1. Heart rate increased from a baseline of 72 to 118 beats per minuteAnswer
  2. Asymmetrical chest wall expansion with absent breath sounds on the right sideAnswer
  3. C
    Arterial blood gas results showing a pH of 7.42 and PaCO2 of 38 mmHg
  4. D
    Expectoration of small amounts of blood-tinged sputum when coughing
  5. Oxygen saturation reading of 87% on room airAnswer
  6. F
    Urine output of 45 mL/hr over the past 2 hours

Answer

The findings that indicate a developing complication are the increased heart rate (tachycardia), asymmetrical chest wall expansion with absent breath sounds, and an oxygen saturation of 87%.
Tachycardia is an early compensatory sign of physiological stress, hemorrhage, or hypoxemia. Asymmetrical chest wall expansion and absent breath sounds on the operative side are classic indicators of a pneumothorax, which is a major complication of a transbronchial biopsy. An oxygen saturation of 87% on room air indicates significant hypoxemia requiring immediate oxygen therapy and medical evaluation.

Step-by-Step Solution

1
Identify the procedure performed and its associated physiological risks.
The client underwent a flexible bronchoscopy with transbronchial biopsy. High-risk complications include pneumothorax, hemorrhage, bronchospasm, and hypoxemia.
Understanding the specific procedure guides the nurse in anticipating and prioritizing potential life-threatening complications.
2
Differentiate between expected post-procedure findings and pathological changes.
Blood-tinged sputum is a normal expectation due to the biopsy trauma. Normal ABG values (pH 7.42, PaCO2 38) and adequate urine output (45 mL/hr) indicate physiological stability.
Recognizing expected findings prevents unnecessary alarm and allows the nurse to focus on true indications of decompensation.
3
Analyze the remaining assessment findings for signs of physiological decompensation.
A sudden onset of tachycardia (HR 118), absent breath sounds with asymmetrical expansion, and hypoxemia (SpO2 87%) are critical indicators of hemorrhage or pneumothorax.
These abnormal findings represent life-threatening complications that require immediate escalation of care and intervention.

Key Concept

Reduction of Risk Potential: Recognition of Post-Procedure Complications
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Topics

Reduction of Risk Potential

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