hard · NCLEX-RN Reduction of Risk Potential
A 57-year-old client with a history of pleural effusion has just returned to the oncology day unit at 1445 following a closed pleural biopsy. Which of the following post-procedure assessments should the nurse integrate into the client's surveillance plan to detect hemothorax or pneumothorax? Select all that apply.
- Monitor for chest pain that worsens with deep breathing or coughing (pleuritic chest pain).
- Reassure the client that a sudden feeling of chest tightness accompanied by tracheal deviation is an expected post-biopsy sensation.
- Assume a post-procedure heart rate of 110 beats/minute is a normal vasovagal response that will resolve without intervention.
- Instruct the client to perform deep, vigorous coughing exercises every 15 minutes to clear airway secretions.
- Assess for dullness to percussion on the affected side.
- Auscultate for diminished or absent breath sounds on the affected side.
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