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Zorluk: OrtaReduction of Risk Potential

A nurse is preparing to assist a healthcare provider with a bedside thoracentesis for an adult client with a large pleural effusion. To ensure client safety and reduce the risk of procedural complications, arrange the following nursing actions in the correct chronological order.

  1. 1Ensure that the informed consent document has been signed and placed in the medical record.
  2. 2Position the client upright on the edge of the bed with arms supported on an overbed table.
  3. 3Instruct the client to remain completely still and refrain from coughing or deep breathing during needle insertion.
  4. 4Apply an occlusive sterile dressing over the puncture site immediately after the needle is withdrawn.
  5. 5Obtain a prescribed post-procedure chest radiograph to evaluate for a potential pneumothorax.

Cevap

The correct sequence is: Verify informed consent, properly position the client, provide intra-procedure safety instructions, apply an occlusive dressing, and finally obtain a post-procedure chest radiograph.
The correct sequence follows the logical progression of care for an invasive bedside procedure: pre-procedure legal verification, anatomical preparation (positioning), intra-procedure safety management, immediate post-procedure site care, and subsequent monitoring for potential iatrogenic complications.

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1
Verify informed consent.
Legal and ethical prerequisites are met.
Informed consent is mandatory before any invasive diagnostic procedure begins.
2
Position the client appropriately.
The client is sitting upright, leaning forward over a bedside table.
This specific orthopneic position maximizes the intercostal spaces and provides optimal access to the pleural cavity while reducing the risk of organ puncture.
3
Provide safety instructions during the procedure.
The client understands to avoid coughing or moving.
Movement during needle insertion can cause the needle to lacerate the lung, leading to a pneumothorax.
4
Apply an occlusive sterile dressing.
The puncture site is immediately sealed.
Sealing the site prevents air from being drawn into the negative-pressure pleural space as the client breathes.
5
Obtain a follow-up chest radiograph.
Diagnostic imaging is performed.
An x-ray confirms the removal of pleural fluid and rules out complications such as pneumothorax or hemothorax.

Anahtar Kavram

Thoracentesis Safety and Risk Reduction
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Konular

Reduction of Risk Potential

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