A nurse is monitoring a client following a thoracentesis.
The nurse should identify which of the following manifestations as a complication and contact the provider immediately?
Discomfort at the puncture site.
Serosanguineous drainage from the puncture site.
Increased heart rate.
Decreased temperature.
The Correct Answer is C
Choice A rationale
Discomfort at the puncture site is a common and expected finding following a thoracentesis due to the needle insertion through the intercostal muscles and parietal pleura. Sensory nerve endings in these tissues are stimulated, causing localized pain. This typically resolves with mild analgesia and does not indicate a significant complication such as pneumothorax or hemorrhage.
Choice B rationale
Serosanguineous drainage from the puncture site, while requiring monitoring, is often a normal finding in small amounts after a thoracentesis. It represents a mixture of serous fluid and blood, indicating minor capillary oozing from the needle tract. Excessive or persistent bleeding would be concerning for hemorrhage, but minimal serosanguineous discharge is not immediately indicative of a major complication.
Choice C rationale
An increased heart rate, or tachycardia, after a thoracentesis can signify significant complications like hypovolemia due to hemorrhage or tension pneumothorax. A tension pneumothorax shifts mediastinal structures, impairing venous return and leading to compensatory tachycardia. Hypovolemia from internal bleeding also triggers a sympathetic response, increasing heart rate to maintain cardiac output.
Choice D rationale
A decreased temperature, or hypothermia, is not typically a direct or immediate complication of a thoracentesis. While systemic reactions can occur in rare instances, a sudden drop in temperature is not a characteristic sign of the most common acute post-procedure complications such as pneumothorax, hemorrhage, or infection, which usually manifest with fever or normal temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
An absolute neutrophil count (ANC) less than 1,000/mm³ indicates neutropenia, which significantly increases the risk of infection. Limiting visitors to healthy adults minimizes exposure to pathogens that could be carried by individuals who are ill or immunocompromised, thereby reducing the risk of opportunistic infections.
Choice B rationale
Taking a rectal temperature is contraindicated in neutropenic clients due to the risk of introducing bacteria from the rectum into the bloodstream, which could lead to bacteremia or sepsis. Oral or axillary temperatures are preferred methods for temperature assessment in immunocompromised individuals to prevent mucosal trauma.
Choice C rationale
Increasing raw produce in the client's diet is contraindicated in neutropenic clients. Uncooked fruits and vegetables can harbor bacteria and fungi that, while usually harmless to individuals with intact immune systems, can cause severe infections in immunocompromised patients due to compromised gut mucosal barriers.
Choice D rationale
Instructing the client to floss his teeth daily is contraindicated in severe neutropenia. Flossing can cause micro-abrasions and bleeding of the gingiva, creating entry points for oral bacteria into the bloodstream, which can lead to systemic infections in a client with a severely compromised immune system.
Correct Answer is C
Explanation
Choice A rationale
Discomfort at the puncture site after a thoracentesis is a common and expected finding due to tissue trauma from needle insertion. It typically resolves with mild analgesics and does not indicate a severe complication requiring immediate provider notification, unless pain is excessive or accompanied by other concerning symptoms.
Choice B rationale
Serosanguineous drainage from the puncture site, characterized by a mix of blood and serous fluid, is often a normal finding after a thoracentesis. It indicates minor capillary leakage from the needle insertion. Excessive or bright red blood would be concerning, but serosanguineous drainage within normal limits typically does not require immediate intervention.
Choice C rationale
An increased heart rate (tachycardia) following a thoracentesis can indicate several serious complications, such as a pneumothorax, internal bleeding, or hypovolemia. A pneumothorax, a common complication, leads to reduced lung expansion and compensatory tachycardia. Therefore, this finding warrants immediate investigation and notification of the provider. Normal heart rate ranges for adults are typically 60-100 beats per minute.
Choice D rationale
A decreased temperature (hypothermia) is not a typical or expected complication following a thoracentesis. While mild temperature fluctuations can occur post-procedure, a significant decrease would require investigation for other underlying causes and is not directly indicative of a common thoracentesis complication. Normal body temperature is around 37°C (98.6°F).
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