A practical nurse (PN) is assisting a healthcare provider with a bedside thoracentesis for a client diagnosed with a large pleural effusion. In what order should the PN perform the following actions to minimize the risk of complications and ensure client safety? Arrange the actions from first to last.
- 1Verify that the informed consent form has been signed by the client and placed in the medical record.
- 2Position the client sitting upright on the edge of the bed, leaning forward with arms resting on an overbed table.
- 3Monitor the client's oxygen saturation and respiratory effort continuously while the pleural fluid is being aspirated.
- 4Apply a sterile occlusive dressing to the puncture site immediately after the provider withdraws the needle.
- 5Prepare the client for a prescribed post-procedure chest X-ray to evaluate for the presence of a pneumothorax.
Cevap
The correct sequence of actions requires the practical nurse to first verify informed consent, position the client safely to expand the ribs, monitor respiratory status during aspiration, apply an occlusive dressing immediately upon needle withdrawal, and finally ensure a follow-up chest X-ray is completed.
Risk reduction during invasive bedside procedures follows a chronological progression to protect the client. It begins with pre-procedural safety checks (verifying consent), moves to optimal anatomical preparation (upright leaning position) to prevent injury, involves continuous intra-procedural vigilance (oxygen saturation monitoring) for acute complications, utilizes immediate post-procedural site care (occlusive dressing) to prevent air entry, and concludes with post-procedural diagnostic verification (chest X-ray) to definitively rule out a collapsed lung.
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Anahtar Kavram
Nursing responsibilities and complication prevention during a thoracentesis