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Zorluk: OrtaReduction of Risk Potential

Following the removal of 1,5001,500 mL of pleural fluid via a right-sided thoracentesis, a client suddenly develops acute respiratory distress. The continuous monitor displays a heart rate of 128128 beats/minute and a blood pressure of 84/5284/52 mm Hg. Physical examination reveals absent breath sounds on the right side and a leftward tracheal shift. Which of the following is the priority nursing action?

  1. A
    Assist the client into a right lateral recumbent position
  2. B
    Encourage pursed-lip breathing and monitor for further changes
  3. Gather equipment for an immediate needle thoracostomy and chest tube placementCevap
  4. D
    Draw a sample for stat arterial blood gas analysis

Cevap

Gather equipment for an immediate needle thoracostomy and chest tube placement.
The client's sudden respiratory distress, absent unilateral breath sounds, hypotension, tachycardia, and tracheal deviation are classic signs of a tension pneumothorax. This is a life-threatening complication of thoracentesis that causes obstructive shock. The condition requires immediate decompression via needle thoracostomy or chest tube placement. The nurse must recognize these signs of decompensation and immediately prepare the necessary equipment for the provider.

Adım Adım Çözüm

1
Analyze the post-procedure clinical presentation.
The client exhibits sudden respiratory distress, absent unilateral breath sounds, hypotension, tachycardia, and a tracheal shift.
Identifying these classic signs is necessary to diagnose a tension pneumothorax, a known severe complication of thoracentesis.
2
Determine the physiological impact of the complication.
Trapped air in the pleural space is rapidly increasing intrathoracic pressure, collapsing the right lung, and compressing the heart and great vessels.
This compression leads to decreased venous return and obstructive shock, explaining the severe hypotension and tachycardia.
3
Prioritize the required nursing intervention based on ABC principles.
Immediate mechanical decompression of the pleural space is required to restore cardiac output and ventilation.
Gathering equipment for needle decompression and chest tube insertion prepares for the only definitive life-saving treatment.

Anahtar Kavram

Recognition and emergency management of a tension pneumothorax following thoracentesis.
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Konular

Reduction of Risk Potential

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