Medical Surgical Pleural Effusion & Thoracentesis #1

Question

The nurse is caring for a client following a thoracentesis. The nurse contacts the health care provider because of which finding?

Answers

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

      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.

  2. Crackles remain unchanged since previous assessment.
    • Rationale:

      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.

  3. Symmetrical chest expansion.
    • Rationale:

      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.

  4. Respiratory rate of 26 breaths per minute.
    • Rationale:

      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.

Overview

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.

Explanation

Learning Outcomes

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.

Video Rationale