# A nurse is caring for a 45-year-old client with pleural effusion who is scheduled for thoracentesis. Which action should the nurse take to ensure client safety during the procedure? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541311 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a 45-year-old client with pleural effusion who is scheduled for thoracentesis. Which action should the nurse take to ensure client safety during the procedure? ## 보기 1. Position the client supine with arms extended overhead 2. Administer sedation to keep the client completely still 3. Position the client sitting upright and leaning forward over a bedside table **✔ 정답** 4. Have the client lie on the unaffected side in lateral position **정답: 3** ## 해설 Upright sitting with forward lean maximizes pleural space access and fluid drainage during thoracentesis. Other positions (supine, lateral) or sedation increase risks like pneumothorax or inadequate drainage. ## 심화 해설 Understanding the Procedure and Positioning Rationale Thoracentesis is an invasive procedure performed to remove fluid from the pleural space, typically to relieve respiratory compromise caused by a large pleural effusion. For the procedure to be performed safely, the primary anatomical goal is to access the pleural cavity by inserting a needle over the superior aspect of a rib. This technique is taught to avoid the neurovascular bundle, which runs along the inferior border of each rib [2]. However, the safety of this landmark-based approach is not absolute because the intercostal arteries (ICAs) can be highly tortuous and are not always shielded by the rib, creating a risk of iatrogenic bleeding [2][3]. To maximize safety and facilitate access, the client must be positioned to widen the intercostal spaces and allow the fluid to collect dependently. The correct action is to position the client sitting upright and leaning forward over a bedside table. This posture achieves several critical safety objectives. It increases the separation between the ribs, providing a larger target window for needle insertion. It also allows the pleural fluid to pool at the posterior costophrenic angle, which is the most dependent part of the pleural space in an upright position. This makes the effusion easier to locate and drain, reducing the risk of puncturing the lung or diaphragm . Analysis of Incorrect Options Positioning the client supine with arms extended overhead (Option 1) is incorrect and potentially dangerous. In a supine position, the pleural fluid layers out posteriorly, making it much harder to access without risking injury to the lung. This position does not optimally widen the intercostal spaces and is not the standard for a non-emergent, posterior approach. Administering sedation to keep the client completely still (Option 2) is not a standard nursing action for safety during thoracentesis. While the client needs to remain still, deep sedation can suppress respiratory drive, which is hazardous in a client already experiencing respiratory compromise from the effusion . The procedure is typically performed under local anesthesia, allowing the client to follow commands and breathe spontaneously, which is a key safety measure. Having the client lie on the unaffected side in a lateral position (Option 4) is a position sometimes used for chest tube insertion but is not the standard for a routine thoracentesis. This position can make it more difficult to access the dependent, fluid-filled area and does not provide the same degree of intercostal space widening as the upright, forward-leaning position. The Critical Safety Link: Anatomical Variability and Imaging The clinical significance of proper positioning is amplified by the anatomical reality that the intercostal artery is not a static structure safely tucked under the rib. Computed tomography studies have demonstrated that the ICA can be exposed in the intercostal space, not just under the rib's protection [2]. This variability is why a simple landmark technique does not guarantee safety. By positioning the client upright and leaning forward, the nurse helps create the widest possible access point, giving the clinician the best chance to visualize the anatomy and avoid vascular structures, especially when the procedure is augmented with point-of-care ultrasound (POCUS) or color Doppler to screen for the ICA [3]. The nurse's role in correctly positioning the client is therefore a direct, non-negotiable intervention to minimize the risk of hemorrhagic complications and ensure the procedure's success.References (research sources) - [2]The Sound of Safety: DIVOT (Doppler Imaging for Vascular Orientation in Thoracic Procedures) Protocol.Research articleFraser A, Brenner DS, Coghlan M, Andrade H, Haouili M, Carlos WG, Jackson E. (2025) · DOI: 10.24908/pocusj.v10i01.18071 - [3]Intercostal Artery Screening with Color Doppler Thoracic Ultrasound in Pleural Procedures: A Potential Yet Underexplored Imaging Modality for Minimizing Iatrogenic Bleeding Risk in Interventional Pulmonology.Research articleMarchi G, Cinquini S, Tannura F, Guglielmi G, Gelli R, Pantano L, Cenerini G, Wandael V, Vivaldi B, Coltelli N, Martinelli G, Celi A, Fanni SC, Serradori M, Gherardi M, Gabbrielli L, Pistelli F, Carrozzi L. (2025) · DOI: 10.3390/jcm14176326 ## 임상 시나리오 Clinical Safety Guide: Thoracentesis Positioning The primary safety action during thoracentesis is positioning the client **sitting upright, leaning forward over a bedside table**. This position widens the intercostal spaces and allows fluid to pool in the posterior costophrenic angle, minimizing the risk of pneumothorax or diaphragmatic puncture. Key Procedural Steps - Confirm informed consent and verify the correct site using ultrasound guidance when available. - Instruct the client to remain still and avoid coughing or sudden movements during needle insertion. - Monitor vital signs, oxygen saturation, and for signs of complications such as hemoptysis, hypotension, or unilateral chest pain. Post-Procedure Nursing Care - Assess the puncture site for bleeding, hematoma, or air leakage. - Obtain a post-procedure chest X-ray to evaluate for iatrogenic pneumothorax. - Document the amount, color, and characteristics of drained fluid, and label specimens appropriately for laboratory analysis. ## 핵심 개념 - **Thoracentesis** — An invasive procedure to remove fluid from the pleural space using a needle inserted over the superior rib margin to avoid the neurovascular bundle. - **Pleural Effusion** — An abnormal accumulation of fluid in the pleural cavity that can cause respiratory compromise by compressing the lung. - **Costophrenic Angle** — The most dependent part of the pleural space in an upright position where fluid collects, making it the target site for thoracentesis. - **Neurovascular Bundle** — A structure containing intercostal nerves and vessels running along the inferior border of each rib, which must be avoided during needle insertion. - **Intercostal Space** — The anatomical space between two ribs that is widened by leaning forward to provide a safer access window for the thoracentesis needle. ## 같은 주제 문제 - [A nurse is assessing a patient with suspected pleural effusion. 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