NCLEX · Reduction of Risk Potential

What is the most important nursing assessment after a thoracentesis procedure?

Correct answer

Respiratory status (rate, effort, oxygen saturation, breath sounds) for signs of pneumothorax

  1. A Pupil response
  2. B Bowel sounds
  3. C Bladder distention
  4. D Respiratory status (rate, effort, oxygen saturation, breath sounds) for signs of pneumothorax

Why this is the answer

Thoracentesis is the insertion of a needle through the chest wall to remove fluid from the pleural space. Main complications: (1) Pneumothorax — air enters the pleural space, possibly causing lung collapse; signs include sudden shortness of breath, sharp chest pain, decreased or absent breath sounds on affected side, tracheal deviation (large pneumothorax), hypoxia; (2) Bleeding; (3) Re-expansion pulmonary edema (if too much fluid removed too quickly); (4) Infection. Post-procedure nursing: (1) Position the client upright or on the unaffected side initially; (2) Monitor respiratory status frequently (vital signs every 15 minutes for 1 hour, then every hour, then per protocol); (3) Auscultate breath sounds bilaterally and compare to pre-procedure; (4) Monitor for shortness of breath, chest pain, hemoptysis, hypoxia; (5) Chest x-ray usually ordered to verify lung expansion and rule out pneumothorax; (6) Document fluid removed (color, character, amount). Report sudden change in respiratory status immediately. The same vigilance applies after any chest procedure: central line insertion, lung biopsy, chest tube placement.
Source: NCLEX-RN, Reduction of Risk — Post-Thoracentesis

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About this topic: Reduction of Risk Potential

Reduction of risk potential questions cover recognising changes in condition, interpreting labs and diagnostics, pre- and post-procedure care, and preventing complications before they develop. This is one of 6 RN: Physiological Integrity questions on reduction of risk potential, each with a full explanation on a single study page.

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