Medical Surgical Pleural Effusion & Thoracentesis #1
The nurse is caring for a client following a thoracentesis. The nurse contacts the health care provider because of which finding?
- Diminished breath sounds on the affected side.
This answer is correct because following a thoracentesis, the nurse will monitor for signs of pneumothorax which may be a complication of the procedure. Diminished breath sounds may be an early sign. Other signs may include dyspnea, retractions, increased respiratory rate, and cyanosis.
- Crackles remain unchanged since previous assessment.
This answer is not correct because crackles, though not normal, remained unchanged over previous assessment, while diminished breath sounds represent new findings consistent with complications following a thoracentesis.
- Symmetrical chest expansion.
This answer is not correct because symmetrical chest expansion is a normal finding. Diminished breath sounds on the side of the procedure is a key indicator of a pneumothorax and the provider should be alerted to this finding immediately.
- Respiratory rate of 26 breaths per minute.
This answer is not correct because, while a respiratory rate of 26 breaths/min is abnormal, it does not signify complications alone. Respiratory rate is generally between 12-18 breaths per minute and varies with age, gender, and condition.
The focus of this question is to be able to correctly determine a potential complication following a thoracentesis. Diminished breath sounds on the side of the procedure could indicate a pneumothorax.
A thoracentesis is a procedure in which needle decompression is used to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. Because a large bore needle is inserted into the pleural space during thoracentesis, one potential complication of the procedure is pneumothorax. Diminished breath sounds on the side of the procedure is a key indicator of a pneumothorax and the provider should be alerted to this finding immediately.
Test Taking Tip
The correct answer can be determined here by process of elimination. Symmetrical chest expansion is a completely normal finding. A respiratory rate of 26 breaths per minute alone does not provide enough information to make a determination that a complication has occurred. Crackles that have remained unchanged since the procedure indicate that the client’s condition has not deteriorated since the procedure and is therefore not a priority finding.