# Eight minutes after 900 mL of right pleural fluid is removed by thoracentesis, a client develops severe dyspnea and pleuritic pain. Oxygen saturation falls to 83%, blood pressure to 76/42 mm Hg, and heart rate rises to 134/min. Breath sounds are absent on the right, neck veins are distended, and the trachea is displaced to the left. Complete the bowtie by selecting the complication, two actions the nurse should take, and two parameters the nurse should monitor.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=604459&lang=en  
> language: en  
> subject: Complications of Procedures  
> category: ROR

## Question

Eight minutes after 900 mL of right pleural fluid is removed by thoracentesis, a client develops severe dyspnea and pleuritic pain. Oxygen saturation falls to 83%, blood pressure to 76/42 mm Hg, and heart rate rises to 134/min. Breath sounds are absent on the right, neck veins are distended, and the trachea is displaced to the left. Complete the bowtie by selecting the complication, two actions the nurse should take, and two parameters the nurse should monitor.

Condition

Select 1
Re-expansion pulmonary edema
Right tension pneumothorax
Procedure-related hemothorax
Vasovagal reaction

Actions to take

Select 2
Stop the procedure, give high-concentration oxygen, and activate emergency support
Begin noninvasive positive-pressure ventilation while awaiting chest imaging
Prepare immediate pleural decompression and chest drainage without waiting for routine imaging
Obtain type and crossmatch before addressing the respiratory compromise
Place the client flat and observe for spontaneous blood-pressure recovery

Parameters to monitor

Select 2
Serial hemoglobin and increasing pleural dullness as the primary response markers
Oxygen saturation, breath sounds, and work of breathing after decompression
Temperature and white blood cell count over the next 24 hours
Blood pressure, heart rate, and peripheral perfusion after decompression
Serum sodium and measured osmolality

## Explanation

Unilateral absent breath sounds, contralateral tracheal displacement, hypoxemia, jugular venous distention, and shock indicate tension pneumothorax. Oxygen and emergency decompression cannot wait for routine imaging; respiratory status and hemodynamic perfusion show the immediate response.

## In-depth explanation

Correct answer
Right tension pneumothorax; emergency oxygen and support; immediate decompression and drainage; monitor respiratory status and hemodynamic perfusion.
Why it fits
The abrupt unilateral ventilation loss with tracheal displacement and obstructive shock after thoracentesis identifies tension pneumothorax rather than pulmonary edema, hemothorax, or a vasovagal event.
Action rationale
The nurse stops the procedure, supports oxygenation, summons emergency help, and prepares immediate decompression. Routine imaging must not delay treatment in an unstable client with classic findings.
Monitoring rationale
Improving oxygen saturation, breath sounds, work of breathing, blood pressure, heart rate, and perfusion demonstrate relief of intrathoracic pressure and obstructive shock.
NCLEX rule
For an immediately life-threatening breathing problem, treat first and reassess the physiologic response; do not choose a test that delays definitive treatment.
Why the alternatives fail
Positive pressure before decompression can worsen the tension physiology. Type and crossmatch, observation, infection markers, and serum osmolality do not address or measure the immediate response to decompression.
**Sources**
- British Thoracic Society — Clinical Statement on Pleural Procedures

- Joint Trauma System — Wartime Thoracic Injury CPG

## Key concepts

- **Tension pneumothorax** — Progressive pleural pressure that collapses the affected lung and impairs venous return, causing respiratory distress and obstructive shock.
- **Pleural decompression** — Emergency release of trapped pleural air followed by definitive chest drainage.

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