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Zorluk: OrtaReduction of Risk Potential

A nurse is assessing a client who underwent a bedside thoracentesis 1 hour ago to drain a large pleural effusion. To reduce the risk of a life-threatening complication, which assessment finding requires the most immediate intervention by the nurse?

  1. Sudden-onset tachypnea, asymmetric chest wall expansion, and absent breath sounds on the procedural sideCevap
  2. B
    An arterial blood gas (ABG) report showing a pH of 7.37, PaCO2 of 42 mm Hg, and PaO2 of 94 mm Hg
  3. C
    The client resting comfortably in a high-Fowler's position, leaning slightly forward
  4. D
    A report of mild, localized tenderness at the needle insertion site that worsens with deep inspiration

Cevap

The sudden onset of tachypnea, asymmetric chest wall expansion, and absent breath sounds on the procedural side.
The correct answer identifies the hallmark signs of a pneumothorax: tachypnea, unequal chest expansion, and diminished or absent breath sounds on the affected side. A pneumothorax is a severe, life-threatening complication of a thoracentesis that requires immediate medical intervention, such as chest tube placement, to re-expand the lung.

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1
Analyze the procedure and its associated risks.
A thoracentesis involves inserting a needle into the pleural space. The most significant immediate risk is a pneumothorax (lung collapse) due to inadvertent puncture of the lung tissue.
Understanding the high-risk complications of a specific procedure directs the focused assessment.
2
Evaluate the clinical significance of each option.
The ABG values are normal, the high-Fowler's position is beneficial, and mild insertion site pain is expected. Asymmetric chest expansion and absent breath sounds, however, indicate a loss of lung inflation.
Differentiating between expected outcomes, normal variants, and pathological indicators is essential for safe triage.
3
Prioritize the findings based on the ABCs (Airway, Breathing, Circulation).
The finding indicating a pneumothorax directly compromises breathing and oxygenation, making it the highest priority.
Life-threatening respiratory compromise always takes precedence over expected procedural discomfort or normal physiological findings.

Anahtar Kavram

Thoracentesis Complications and Pneumothorax Assessment
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Konular

Reduction of Risk Potential

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