A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast.

The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

A) Incorrect- Dullness bilaterally on percussion is not a normal finding, but it is not an immediate concern after thoracentesis. It may indicate fluid accumulation or consolidation in both lungs, which could be related to other conditions such as pneumonia or heart failure.
B) Incorrect- Serosanguinous drainage from the chest tube is expected after thoracentesis, as long as it is not excessive or continuous. The nurse should monitor the amount and color of the drainage and document it accordingly.
C) Incorrect- Diminished breath sounds in the left lower lobe are also expected after thoracentesis, as the procedure removes fluid and air from the pleural space and reduces lung expansion. The nurse should auscultate the lungs before and after the procedure and compare the findings. The breath sounds should improve gradually as the lung re-expands.
D) Correct- This is a sign of tension pneumothorax, which is a life-threatening complication of thoracentesis. Tension pneumothorax occurs when air accumulates in the pleural space and creates positive pressure that pushes the mediastinum (the heart, great vessels, and trachea) to the opposite side of the chest. This can impair venous return, cardiac output, and respiratory function. The nurse should report this finding to the healthcare provider immediately and prepare to assist with needle decompression or chest tube insertion.

A.Protect the site from getting wet during bathing. While it is important to avoid prolonged soaking, gentle rinsing with water is usually allowed. Complete avoidance of water is not typically necessary.Gentle bathing is important for hygiene.

B.Gently patting the skin dry after rinsing with water is a good practice as it helps to minimize friction and irritation to the sensitive skin. Rubbing or scrubbing the skin should be avoided.

C. Applying moisturizers to prevent dry skin can be beneficial for overall skin health, but it is important to consult with the healthcare team and follow specific instructions regarding the use of moisturizers during radiation therapy. Certain types of moisturizers or creams may interfere with the radiation treatment or cause skin irritation. Frequent application is not always necessary. Over-hydration can soften the skin and increase vulnerability.

D.Using a sponge to debride the affected area is not recommended during radiation therapy. The skin in the radiation treatment field is already sensitive and prone to damage, and using a sponge for debridement can further traumatize the skin. It is important to avoid any abrasive or rough handling of the treated skin.