hard · NCLEX-RN risk-reduction

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.

1. Monitor for chest pain that worsens with deep breathing or coughing (pleuritic chest pain).
2. Reassure the client that a sudden feeling of chest tightness accompanied by tracheal deviation is an expected post-biopsy sensation.
3. Assume a post-procedure heart rate of 110 beats/minute is a normal vasovagal response that will resolve without intervention.
4. Instruct the client to perform deep, vigorous coughing exercises every 15 minutes to clear airway secretions.
5. Assess for dullness to percussion on the affected side.
6. Auscultate for diminished or absent breath sounds on the affected side.

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