# A nurse is caring for a client with pleural effusion who is scheduled for thoracentesis. Which nursing intervention should the nurse implement immediately after the procedure?

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> subject: Adult Health

## 문제

A nurse is caring for a client with pleural effusion who is scheduled for thoracentesis. Which nursing intervention should the nurse implement immediately after the procedure?

## 보기

1. Encourage the client to cough and deep breathe vigorously to prevent pneumonia
2. Position the client on the unaffected side and monitor for signs of pneumothorax **✔ 정답**
3. Ambulate the client within 30 minutes to promote lung expansion
4. Remove the dressing and inspect the puncture site for bleeding every 15 minutes

**정답: 2**

## 해설

Positioning on the unaffected side helps prevent complications and allows monitoring for pneumothorax, the most serious potential complication. Other options are either contraindicated (vigorous coughing, early ambulation) or less immediate priorities (frequent dressing removal).

## 심화 해설

Immediate Post-Thoracentesis Nursing Care

Following a thoracentesis, the priority nursing intervention is to position the client on the unaffected side and monitor for signs of pneumothorax. This action directly addresses the most common and potentially life-threatening complication of the procedure.

Rationale for Positioning and Monitoring

Thoracentesis involves inserting a needle through the chest wall into the pleural space to drain fluid. This inherently risks puncturing the visceral pleura of the lung, allowing air to enter the pleural cavity and causing a pneumothorax. Positioning the client with the unaffected (non-procedural) lung in a dependent position promotes optimal expansion of the healthy lung for gas exchange. Simultaneously, keeping the affected side slightly compressed can help to mechanically splint the puncture site, potentially limiting the ingress of air if a small leak is present. The nurse must vigilantly assess for signs of pneumothorax, which include sudden onset of sharp chest pain, tachypnea, dyspnea, tachycardia, tracheal deviation (in a tension pneumothorax), and diminished or absent breath sounds on the affected side. As noted in the literature, thoracentesis "can cause several complications," making this post-procedural monitoring a critical safety step [3].

Why Other Options Are Incorrect

-   Option 1: Encourage the client to cough and deep breathe vigorously. While deep breathing and coughing are important to promote lung expansion and prevent atelectasis after the lung has been re-expanded, it is not the immediate priority. Vigorous coughing immediately post-procedure could increase intrathoracic pressure and potentially worsen an air leak at the puncture site, increasing the risk of a pneumothorax. Gentle deep breathing is encouraged after the initial assessment period.

-   Option 3: Ambulate the client within 30 minutes. Ambulation is contraindicated immediately after thoracentesis. The client should remain on bed rest, typically in the side-lying position, for a specified period to allow the puncture site to begin sealing and to facilitate monitoring for complications. A post-procedure chest X-ray is also standard to evaluate for pneumothorax and the degree of lung re-expansion before activity is advanced.

-   Option 4: Remove the dressing and inspect the puncture site every 15 minutes. The initial dressing applied after the procedure is a sterile, occlusive dressing designed to seal the wound and prevent air from entering the pleural space. Removing it frequently disrupts this protective barrier and increases the risk of infection and pneumothorax. The nurse should monitor the site by inspecting the dressing for any overt bleeding or drainage without routinely removing it, and assess the client's respiratory status as the primary indicator of a complication. The therapeutic goal of the procedure is to relieve symptoms from large effusions that can cause "respiratory compromise or hemodynamic instability," and the post-procedure care must safeguard the stability achieved .References (research sources)

- [3]Construction of a simulation scenario and a low-cost simulator for teaching thoracentesis procedural technique: a validation study.Research articleAntequera Moron R, de Oliveira Costa RR, Cardozo V, Dos Santos CF, Marton Filho MA, Mazzo A. (2025) · DOI: 10.1186/s12909-025-07381-7

## 임상 시나리오

Post-Thoracentesis MonitoringImmediate Positioning and Complication Surveillance
Position the client on the unaffected side to promote expansion of the healthy lung and mechanically splint the puncture site. Monitor for pneumothorax signs: sudden sharp chest pain, tachypnea, dyspnea, tracheal deviation, and diminished breath sounds on the affected side.

CautionDo not encourage vigorous coughing immediately post-procedure; it may increase intrathoracic pressure and worsen an air leak. Keep the initial occlusive dressing dry and intact for the prescribed time to maintain a seal.

## 핵심 개념

- **Thoracentesis** — A procedure to remove fluid from the pleural space using a needle inserted through the chest wall.
- **Pneumothorax** — A collection of air in the pleural space causing partial or complete lung collapse, a key complication of thoracentesis.

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