# A nurse is caring for a 65-year-old patient with congestive heart failure who has developed a large pleural effusion and is experiencing significant dyspnea (vital signs: BP 140/85 mmHg, HR 95 bpm, RR 24/min, O2 sat 88% on room air). The patient is scheduled for thoracentesis and appears anxious. Which nursing action is the priority to ensure patient safety during the procedure? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541310 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a 65-year-old patient with congestive heart failure who has developed a large pleural effusion and is experiencing significant dyspnea (vital signs: BP 140/85 mmHg, HR 95 bpm, RR 24/min, O2 sat 88% on room air). The patient is scheduled for thoracentesis and appears anxious. Which nursing action is the priority to ensure patient safety during the procedure? ## 보기 1. Administer prescribed analgesic medication 30 minutes before the procedure 2. Ensure the patient has signed informed consent and understands the procedure 3. Position the patient in a comfortable sitting position leaning forward 4. Verify that a recent chest X-ray has been obtained before the procedure **✔ 정답** **정답: 4** ## 해설 A recent chest X-ray is the priority to confirm fluid location and minimize complications like pneumothorax. Other actions (consent, positioning, analgesia) are important but secondary safety measures. ## 심화 해설 Clinical Context and Priority Setting In a patient with congestive heart failure (CHF) presenting with a large pleural effusion and significant dyspnea, thoracentesis is performed to remove fluid, improve lung expansion, and relieve respiratory distress. The patient’s vital signs—tachypnea (RR 24/min) and hypoxemia (O2 sat 88% on room air)—indicate a compromised respiratory status that requires urgent intervention. When multiple nursing actions are necessary, the priority must be determined using the airway, breathing, and circulation (ABC) framework and by identifying the action that most directly prevents an immediate, life-threatening complication. The procedure itself carries a risk of iatrogenic pneumothorax, and the primary safety measure to mitigate this risk is imaging guidance. Therefore, verifying that a recent chest X-ray has been obtained is the foundational safety step before the procedure begins. Why Verification of a Recent Chest X-ray is the Priority The core safety principle during thoracentesis is the accurate identification of the puncture site to avoid injury to the lung parenchyma, which can cause a pneumothorax. While ultrasound is increasingly used for real-time guidance, a pre-procedure chest X-ray provides a critical baseline assessment of the effusion’s size, location, and the presence of any loculations or atypical anatomy. Research on post-thoracentesis evaluation highlights the importance of imaging in confirming effective pleural space evacuation and lung re-expansion, underscoring that imaging is integral to the procedural safety loop [2]. Without a current image to confirm the effusion’s characteristics, the operator cannot safely determine the needle insertion point, heightening the risk of puncturing the diaphragm, liver, spleen, or lung. This action directly supports the patient’s breathing by ensuring the procedure is performed on the correct anatomical target, making it the highest priority over comfort, consent, or positioning. Analysis of Other Options - Option 1 (Administer prescribed analgesic): While pre-procedural analgesia can reduce anxiety and discomfort, it does not address a life-threatening safety risk. Pain management is an important comfort measure but is secondary to ensuring the procedure can be performed safely without causing a pneumothorax. - Option 2 (Ensure signed informed consent): Informed consent is a legal and ethical requirement, and the nurse must verify it is complete. However, consent is a prerequisite for the procedure, not a direct intra-procedural safety action that prevents a physiological complication like a tension pneumothorax. The immediate physical safety of the patient takes precedence over administrative verification in this urgent scenario. - Option 3 (Position the patient): Positioning the patient in a sitting position, leaning forward, is the correct posture for thoracentesis as it widens the intercostal spaces and pools fluid posteriorly. This is a crucial nursing action, but it is performed after the safety baseline is established. Positioning cannot safely proceed if the puncture site has not been radiographically confirmed, as the fluid location may not be in the typical dependent area. Integration of Evidence and Pathophysiology The rationale for prioritizing imaging verification is rooted in the pathophysiology of pleural effusion in CHF. Elevated hydrostatic pressure from left ventricular dysfunction forces fluid into the pleural space, and when a large effusion accumulates, it compresses the lung, causing dyspnea and ventilation-perfusion mismatch (evidenced by the low O2 saturation). Thoracentesis relieves this compression, but the needle must traverse the chest wall into the pleural space without touching the visceral pleura. A recent chest X-ray delineates the air-fluid level and the relationship of the effusion to the diaphragm and lung markings. The COLLABORATION-II trial protocol emphasizes the ongoing challenge of improving diagnostic yield and safety in pleural procedures, noting that even with advanced imaging like ultrasound-guided biopsy, outcomes can be inadequate without proper visualization . This reinforces that the foundation of any pleural intervention is a clear, pre-procedural image. While artificial intelligence is emerging to enhance the interpretation of pleural disease on imaging, the fundamental clinical step of obtaining and reviewing that image remains the nurse’s responsibility to ensure patient safety . The Nuss procedure study, though focused on a different anatomical condition, similarly highlights that procedural outcomes and complications are closely tied to the precision of the intervention, a principle that directly applies to the risk of barotrauma or organ puncture during thoracentesis .References (research sources) - [2]Post-Thoracentesis Ultrasound versus Chest Radiography for the Evaluation of Effusion Evacuation and Lung Reexpansion: A Multicenter Study.Research articleRatwani A, Grosu HB, Husnain SMN, Sanchez TM, Yermakhanova G, Pannu J, Debiane LG, DePew Z, Yarmus L, Maldonado F, Lentz RJ, Rickman OB, Feller-Kopman D, Arain MH, New H, Chen H, Chen SC, Ost DE, Dana F, Rezai Gharai L, Parker M, Lee PMJ, Khemasuwan D, Shepherd RW, Rahman NM, Shojaee S. (2025) · DOI: 10.1513/annalsats.202410-1095oc ## 임상 시나리오 Clinical Safety Protocol for Thoracentesis The priority nursing action to ensure patient safety during a thoracentesis is to verify that a recent chest X-ray has been obtained. This imaging serves as a critical baseline to confirm the location and size of the pleural effusion, rule out loculations, and guide the puncture site, thereby minimizing the risk of iatrogenic pneumothorax. Key Pre-Procedure Safety Checks - Confirm the chest X-ray was performed within a clinically appropriate timeframe (typically within 24 hours) and is available for the procedural team. - Ensure the correct patient, correct site, and correct procedure are verified as part of a time-out process. - Assess coagulation status (e.g., INR, platelets) to reduce bleeding risk, as ordered. Nursing Responsibilities During the Procedure - Position the patient sitting upright and leaning forward over a bedside table to widen the intercostal spaces; this is important but secondary to imaging verification. - Monitor vital signs and oxygen saturation continuously for signs of re-expansion pulmonary edema or pneumothorax. - Provide emotional support and instruct the patient to avoid coughing or sudden movements during needle insertion. Post-Procedure Monitoring A post-procedure chest X-ray is standard to evaluate for pneumothorax and confirm lung re-expansion. Monitor for sudden onset of chest pain, worsening dyspnea, or tracheal deviation, which may indicate a tension pneumothorax requiring emergency intervention. ## 핵심 개념 - **Thoracentesis** — A procedure to remove fluid from the pleural space using a needle, performed to relieve dyspnea and obtain fluid for analysis. - **Iatrogenic Pneumothorax** — A collapsed lung caused by a medical procedure, such as accidental puncture of the lung during thoracentesis. - **Pleural Effusion** — An abnormal accumulation of fluid in the pleural cavity, commonly caused by heart failure, infection, or malignancy. - **Priority Setting (ABC)** — A triage framework prioritizing Airway, Breathing, and Circulation; used to identify the most critical intervention to prevent immediate harm. ## 같은 주제 문제 - [A nurse is assessing a patient with suspected pleural effusion. Which assessment finding w…](https://mymerci.kr/pages/nclex_q.php?qn_id=541304) - [A nurse is assessing a patient with suspected pleural effusion. Which assessment finding w…](https://mymerci.kr/pages/nclex_q.php?qn_id=541305) - [A nurse is caring for a client with pleural effusion who is scheduled for thoracentesis. W…](https://mymerci.kr/pages/nclex_q.php?qn_id=541306) - [A nurse is caring for a client with pleural effusion who is scheduled for thoracentesis. W…](https://mymerci.kr/pages/nclex_q.php?qn_id=541307) - [A nurse is caring for a client with pleural effusion who underwent thoracentesis. Which nu…](https://mymerci.kr/pages/nclex_q.php?qn_id=541308) - [A nurse is caring for a client who underwent thoracentesis for pleural effusion 2 hours ag…](https://mymerci.kr/pages/nclex_q.php?qn_id=541309) - [A nurse is caring for a 45-year-old client with pleural effusion who is scheduled for thor…](https://mymerci.kr/pages/nclex_q.php?qn_id=541311) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._