Medical Surgical Pleural Effusion & Thoracentesis #4

Question

The nurse is caring for a client status post-thoracentesis for right-sided pleural effusion. Which observation by the nurse constitutes immediate action?

Answers

  1. Symmetrical chest expansion.
    • Rationale:

      This answer is not correct because a symmetrical chest expansion indicates a normal breathing pattern. The nurse would intervene if there were unequal movements of the chest.

  2. Bed in semi Fowler’s position.
    • Rationale:

      This answer is not correct because the bed is in the correct position in semi-Fowler’s position. This position allows for lung expansion and ventilation.

  3. Client lying on their right side.
    • Rationale:

      This answer is correct because the client is laying on the right side, which is the affected side where the thoracentesis was performed. This position is incorrect and would require the nurse to reposition the client and educate as to why. A client post-thoracentesis should lay on the unaffected side with the bad lung up to promote lung expansion.

  4. Low-pitched vesicular breath sounds.
    • Rationale:

      This answer is not correct because these breath sounds are normal. If the nurse auscultated decreased breath sounds, then immediate intervention would be required.

Overview

Post thoracentesis care includes instructing the client on deep breaths after the procedure, keeping bed in the semi Fowler’s position, and having the client lay on the unaffected lung side. Findings that support an immediate intervention are asymmetrical lung expansion with unequal movement of the chest, decreased breath sounds on the affected side, and/or hyperresonance.

Explanation

Learning Outcomes

Post-thoracentesis care includes monitoring the client’s breath sounds, vital signs, and oxygen saturation. The nurse should check the dressing applied to the site of entry for bleeding or drainage. A chest X-ray is always ordered post-thoracentesis to check for a pneumothorax. Findings that support an immediate intervention are asymmetrical lung expansion with unequal movement of the chest, decreased breath sounds on the affected side, and/or hyperresonance.

Test Taking Tip

After a thoracentesis always remember “bad lung up”.

Video Rationale