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Difficulty: Very hardReduction of Risk Potential

A 65-year-old client is 2 hours post-thoracentesis during which 1,500 mL of pleural fluid was removed from the right hemithorax. The client abruptly develops severe dyspnea, a persistent dry cough that progresses to producing frothy sputum, and extreme restlessness.

Assessment findings:
- Vital signs: Blood pressure 88/54 mm Hg, heart rate 124 bpm, respiratory rate 30 breaths/min, SpO2SpO_2 84% on room air.
- Respiratory: Diffuse crackles auscultated over the right lung fields; breath sounds are clear over the left lung. The trachea is midline.
- Arterial Blood Gas (ABG): pHpH 7.26, PaCO2PaCO_2 56 mm Hg, PaO2PaO_2 52 mm Hg, HCO3−HCO_3^- 24 mEq/L.

Which of the following is the most appropriate priority action by the nurse to reduce the client's risk of impending cardiopulmonary arrest?

  1. Position the client with the left side dependent and prepare to initiate continuous positive airway pressure (CPAP).Answer
  2. B
    Place the client in the right lateral decubitus position and administer 100% oxygen via a non-rebreather mask.
  3. C
    Prepare the client for an emergency needle thoracostomy followed by chest tube insertion.
  4. D
    Administer a rapid intravenous bolus of 0.9% sodium chloride to correct the hypotension.

Answer

Position the client with the left side dependent and prepare to initiate continuous positive airway pressure (CPAP).
The client is exhibiting classic signs of re-expansion pulmonary edema (REPE), a rare but life-threatening complication occurring after the rapid removal of a large volume of pleural fluid (typically >1,000 mL). Signs include severe hypoxemia, hypercapnia (as seen on the ABG), hypotension, and unilateral crackles with frothy sputum. The priority is to optimize oxygenation and ventilation. Positioning the client with the unaffected ('good') lung dependent (left lateral decubitus) maximizes perfusion to the healthy lung due to gravity, optimizing the ventilation/perfusion (V/Q) ratio. Concurrently, CPAP provides positive intrathoracic pressure, which helps push fluid out of the alveoli back into the pulmonary interstitium.

Step-by-Step Solution

1
Analyze the clinical presentation and procedure history.
The rapid removal of 1,500 mL of fluid, followed by unilateral right-sided crackles, frothy sputum, and a midline trachea, strongly indicates re-expansion pulmonary edema (REPE).
Identifying the specific complication is necessary to select the appropriate intervention and differentiate it from a pneumothorax.
2
Interpret the Arterial Blood Gas (ABG) and vital signs.
The ABG reveals acute uncompensated respiratory acidosis and severe hypoxemia. The hypotension is a secondary consequence of hypoxia and fluid shifts into the lungs.
Understanding the primary physiological failure prevents inappropriate treatments, such as administering fluid boluses that would worsen pulmonary flooding.
3
Determine the priority positioning and intervention to reduce physiological risk.
Positioning the client with the unaffected left lung dependent (down) and applying CPAP is the priority action.
Placing the 'good lung down' directs blood flow to the well-ventilated lung, optimizing V/Q matching. CPAP reduces alveolar fluid and improves oxygenation.

Key Concept

Re-expansion Pulmonary Edema (REPE) and Ventilation/Perfusion (V/Q) Matching
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Topics

Reduction of Risk Potential

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