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NCLEX-RN

Category - Reduction of Risk

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The nurse is assessing a male client who had a thoracentesis 3 hours ago. A total of 500 ml of fluid have been collected. On assessment, which finding should be reported immediately by the nurse to the physician?

Pain at the insertion site
Uncontrollable coughing
Bilateral crackles on auscultation
Bruising around puncture site

Explanation

Answer - B - Uncontrolled coughing after thoracentesis suggests that the diaphragm has been accidentally punctured. Diaphragm irritation can cause chest pain; therefore, the physician is immediately notified about the client’s condition. Pain on the insertion site, bilateral crackles and bruising around the puncture site are expected findings.

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