A charge nurse is evaluating a newly licensed nurse who is managing a client 12 hours postoperative following a right total pneumonectomy. No chest tube is present. The client's vital signs are: blood pressure 110/70 mmHg, heart rate 98 bpm, respiratory rate 20/min, and oxygen saturation 94% on 2 L/min via nasal cannula. Which action by the newly licensed nurse requires immediate intervention by the charge nurse to prevent a life-threatening complication?
- Assisting the client into a full left lateral decubitus position to optimize ventilation-perfusion matching.Answer
- BRestricting total intravenous fluid intake to 1,000 mL over the next 24 hours as prescribed.
- CCoaching the client to perform hourly incentive spirometry and splinted coughing exercises.
- DDocumenting absent breath sounds and a dull percussion note over the right posterior hemithorax.
Answer
The action that requires immediate intervention is assisting the client into a full left lateral decubitus position (the unoperated side).
The correct answer is the action of positioning the client on their unoperated side. While placing the 'good lung down' is a standard strategy to optimize ventilation-perfusion (V/Q) matching in conditions like unilateral pneumonia, it is strictly contraindicated following a pneumonectomy. Placing a post-pneumonectomy client on their unoperated (left) side allows gravity to pull the heart and mediastinal structures into the empty surgical space. This can cause a catastrophic mediastinal shift, severe compression of the single remaining lung, cardiovascular collapse, and extreme tension on the sutured bronchial stump leading to a blowout. The client should only be positioned supine or on the operated (right) side.
Step-by-Step Solution
Key Concept
Post-pneumonectomy positioning requires placing the client supine or on the operative side to prevent catastrophic mediastinal shift and protect the single remaining lung.
Estimated Time:1m 30s