Nursing Prioritization Delegation Assignment Q 59
You have just finished assisting the physician with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is important to report to the physician?
A. The patient starts crying and says she can't go on with treatment much longer.
B. The patient complains of sharp, stabbing chest pain with every deep breath.
C. The patient's blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min.
D. The patient's dressing at the thoracentesis site has 1 cm of bloody drainage.
Correct Answer: C. The patient’s blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min
Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this.
Option A: A large build up of fluid can make it hard to breathe. Removing some fluid may make the person more comfortable. To remove this fluid for evaluation (testing) or improve a patient’s breathing, a procedure called a thoracentesis is done.
Option B: Discomfort can result from the needle at the time it is inserted. Doctors try to lessen any pain or discomfort by giving a local numbing medicine (local anesthetic). The discomfort is usually mild and goes away once the needle or tube is removed.
Option D: During insertion of the needle, a blood vessel in the skin or chest wall may be accidentally nicked. Bleeding is usually minor and stops on its own. Sometimes, bleeding can cause a bruise on the chest wall.