A 72-year-old client with a history of heart failure is being monitored 30\text{ minutes} … — NCLEX-RN

A $72$ -year-old client with a history of heart failure is being monitored $30\text{ minutes}$ after a bedside therapeutic thoracentesis, during which $1,600\text{ mL}$ of pleural fluid was rapidly removed. Which assessment findings indicate a developing physiological complication that requires immediate rapid response? Select all that apply.

Development of a persistent, hacking cough that produces frothy sputumCevap
Heart rate elevation from $82$ to $118\text{ beats/min}$ accompanied by a narrowing pulse pressureCevap
Asymmetrical chest wall movement with absent breath sounds on the operative sideCevap
D
Arterial blood gas analysis revealing a $\text{pH}$ of $7.39$ , $\text{PaCO}_2$ of $42\text{ mm Hg}$ , and $\text{PaO}_2$ of $89\text{ mm Hg}$ on room air
E
A decrease in respiratory rate from $28\text{ breaths/min}$ before the procedure to $18\text{ breaths/min}$
F
The client independently assumes a lateral recumbent position resting on the unaffected side

Cevap

The findings requiring immediate intervention are the development of a persistent, hacking cough producing frothy sputum; a heart rate elevation with a narrowing pulse pressure; and asymmetrical chest wall movement with absent breath sounds on the operative side.

The correct answers identify findings indicative of major thoracentesis complications: re-expansion pulmonary edema (frothy sputum and coughing), hypovolemic shock due to fluid shifts (tachycardia and narrow pulse pressure), and pneumothorax (asymmetrical chest movement and absent breath sounds). These require immediate life-saving interventions.

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Analyze the procedure and the volume of fluid removed.

The client had a thoracentesis with

1,600\text{ mL}

of fluid removed.

Rapid removal of more than

1,000

1,500\text{ mL}

of pleural fluid significantly increases the risk of hemodynamic instability and pulmonary complications.

Evaluate each finding for signs of re-expansion pulmonary edema, pneumothorax, or shock.

Frothy sputum indicates pulmonary edema; a narrowing pulse pressure with tachycardia indicates shock; asymmetrical chest movement indicates pneumothorax.

These are the most common life-threatening complications of large-volume thoracentesis that require immediate rapid response.

Differentiate expected clinical improvements and normal findings from true complications.

Normal ABG values, a normalized respiratory rate, and resting on the unaffected side are all expected or positive outcomes.

Safe prioritization requires distinguishing between stable/improving clinical status and acute physiological decompensation.

Anahtar Kavram

Post-Thoracentesis Complication Recognition

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