Medical Surgical Chest tube #2

Question

The nurse is assessing a client following a thoracentesis and immediately reports which finding to the health care provider?

Answers

  1. Subcutaneous emphysema around the site.
    • Rationale:

      This answer is correct because subcutaneous emphysema, or crepitus, following a thoracentesis may be a sign of a pneumothorax and should be immediately reported. Promptly following a thoracentesis, the nurse should mark any crepitus and if crepitus expands beyond the markings, this could indicate a pneumothorax and should be reported to the health care provider.

  2. Serous drainage oozing from site.
    • Rationale:

      This answer is not correct because serous oozing or blood oozing may occur at the affected site. This is a normal and expected finding following this procedure and does not need to be reported to the health care provider.

  3. Increased temperature to 100.4°/ 38 C.
    • Rationale:

      This answer is not correct because a low-grade temperature could be attributed to another condition. While a low-grade fever could indicate an infection, signs of an infection due to the procedure would not be evident immediately following the procedure. This is not the most critical finding requiring the nurse to notify the provider.

  4. Diminished breath sounds on the affected side.
    • Rationale:

      This answer is not correct because diminished breath sounds may be attributed to another condition or the procedure; however, crepitus is MOST important to report. Diminished breath sounds are more than likely to be expected and can be attributed to the underlying condition that required the client to need a thoracentesis.

Overview

The focus of this question is the recognition of the most critical potential complication following a thoracentesis. The palpation of expanding subcutaneous emphysema or crepitus, around the thoracentesis insertion site is most likely an indication that a pneumothorax has occurred.

Explanation

Learning Outcomes

Subcutaneous emphysema, or crepitus, produces a “rice crispies” feeling upon palpation. This is caused by the leakage of air into the subcutaneous space. The finding of subcutaneous emphysema around the insertion site post-thoracentesis could indicate that the lung was inadvertently punctured during the procedure and should be immediately reported to the provider. A tension pneumothorax could result if this is not immediately recognized and treated.

Test Taking Tip

Two of the answer choices in this question indicate the presence of infection (drainage and fever). When two answer choices are very similar, they can most likely be ruled out as correct. By ruling those two answer choices out, only 1 & 4 remain as possibilities. #4 may then be ruled out as diminished breath sounds in a client who required a thoracentesis is an expected finding.

Video Rationale