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Difficulty: MediumPhysiological Adaptation

A client is being monitored on the medical-surgical unit shortly after a therapeutic thoracentesis that removed a large volume of pleural fluid. Upon entering the room, the nurse observes that the client is newly restless and confused. The client's respiratory rate is 28 breaths per minute, the apical pulse is 114 beats per minute, and the blood pressure has trended down to 88/64 mm Hg. Which of the following immediate nursing actions should be implemented? (Select all that apply)

  1. Provide supplemental oxygen using a high-flow delivery deviceAnswer
  2. Auscultate bilateral lung fields and assess for tracheal deviationAnswer
  3. Activate the rapid response team or notify the healthcare providerAnswer
  4. D
    Attribute the vital sign changes to expected procedure-related anxiety and reassess in one hour
  5. E
    Delegate the unlicensed assistive personnel to reassess the vital signs in 15 minutes
  6. F
    Place the client in a flat, supine position to promote venous return to the heart

Answer

The correct actions are to provide supplemental oxygen, auscultate the lung fields to assess for tracheal deviation, and activate the rapid response team.
The correct actions prioritize airway, breathing, and circulation in a rapidly deteriorating client. Providing supplemental oxygen directly addresses hypoxemia, assessing lung sounds and tracheal position identifies the specific etiology of the distress (such as a tension pneumothorax), and activating the rapid response team ensures the client receives life-saving advanced care.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client exhibits tachycardia, hypotension, tachypnea, and new-onset confusion shortly after an invasive pleural procedure.
Identifying abnormal physiological findings is the first step in recognizing an acute post-procedure complication such as a pneumothorax, hemothorax, or impending shock.
2
Prioritize nursing interventions using the Airway, Breathing, Circulation (ABC) framework.
Oxygen administration and a focused respiratory assessment are identified as the immediate priorities.
Hypoxemia and potential respiratory collapse must be addressed immediately to prevent cardiac arrest.
3
Determine the need for escalated medical care.
The rapid response team is activated.
The client is hemodynamically unstable and requires advanced medical interventions beyond independent nursing scope.
4
Evaluate the remaining options for safety and appropriateness.
Delegating to UAP, ignoring the symptoms as anxiety, and flat supine positioning are rejected as unsafe.
Unstable clients require RN assessment, signs of shock must never be dismissed, and supine positioning worsens respiratory distress.

Key Concept

Recognition and immediate management of acute physiological complications (such as tension pneumothorax or shock) following a thoracentesis.
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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