Increased heart rate.

Discomfort at the puncture site.

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?

Choice A rationale
The client has an increased risk for bleeding. Cisplatin is a chemotherapy drug that can cause myelosuppression, leading to a decrease in platelets (thrombocytopenia). However, the client’s platelet count is 170,000/mm³, which is within the normal range (150,000-450,000/mm³).
Therefore, the client does not have an increased risk for bleeding based on the current CBC results.
Choice B rationale
The client should receive an erythropoiesis stimulating agent. Cisplatin can cause anemia due to myelosuppression, which would be indicated by a low hemoglobin (Hgb) and hematocrit (Hct). However, the client’s Hgb is 12.1 g/dL and Hct is 36.5%, both of which are within normal limits (Hgb: 12-16 g/dL for females, Hct: 36-48% for females). Therefore, there is no immediate need for an erythropoiesis stimulating agent based on the current CBC results.
Choice C rationale
The client should receive a diet with increased protein. While a high-protein diet can be beneficial for cancer patients to help maintain muscle mass and support recovery, the CBC results do not indicate a specific need for increased protein intake. The client’s albumin level is 4.5 g/dL, which is within the normal range (3.5-5.0 g/dL), indicating adequate protein status.
Choice D rationale
The client has an increased risk of infection. Cisplatin can cause neutropenia, a condition characterized by a low white blood cell (WBC) count, which increases the risk of infection. The client’s WBC count is 1,400/mm³, which is significantly below the normal range (4,000- 11,000/mm³). This indicates severe neutropenia, putting the client at a high risk for infections. Therefore, it is crucial for the nurse to consider infection prevention measures for this client.

Choice A rationale
Supraventricular tachycardia (SVT) is characterized by a rapid heart rate originating above the ventricles, typically with a regular rhythm and identifiable P waves. The described ECG strip shows an irregular rhythm and an inability to identify P waves, which is not consistent with SVT5.
Choice B rationale
Atrial fibrillation (AF) is characterized by an irregularly irregular rhythm, absence of identifiable P waves, and variable PR intervals. The ECG findings of an irregular rhythm, inability to identify P waves, and a QRS duration of 0.10 seconds are consistent with AF6.
Choice C rationale
Sinus bradycardia is characterized by a regular rhythm with a heart rate less than 60 beats per minute and identifiable P waves preceding each QRS complex. The described ECG strip shows an irregular rhythm and an inability to identify P waves, which is not consistent with sinus bradycardia.
Choice D rationale
First-degree heart block is characterized by a prolonged PR interval with a regular rhythm. The described ECG strip shows an irregular rhythm and an inability to measure the PR interval, which is not consistent with first-degree heart block.