A nurse is caring for a client following a bronchoscopy with moderate sedation. Which of the following actions should the nurse take? (Select all that apply.)
Assess the client’s gag reflex before offering oral intake.
Listen to the client’s breath sounds.
Monitor the client’s oxygen saturation.
Monitor the client for manifestations of bleeding.
Assess the client’s puncture site.
Observe the client for manifestations of a pneumothorax.
Correct Answer : A,B,C,D,F
Choice A rationale
Assessing the client’s gag reflex before offering oral intake is essential to prevent aspiration. The gag reflex may be diminished after moderate sedation and the use of local anesthetics during bronchoscopy.
Choice B rationale
Listening to the client’s breath sounds is important to detect any abnormalities, such as wheezing, crackles, or decreased breath sounds, which could indicate complications like bronchospasm or pneumothorax.
Choice C rationale
Monitoring the client’s oxygen saturation is crucial to ensure adequate oxygenation and detect any signs of respiratory distress or hypoxemia following the procedure.
Choice D rationale
Monitoring the client for manifestations of bleeding is necessary because bronchoscopy can cause trauma to the airways, leading to bleeding. Signs of bleeding may include hemoptysis or a drop in hemoglobin levels.
Choice E rationale
Assessing the client’s puncture site is not applicable in this context, as bronchoscopy does not involve a puncture site. This option is incorrect.
Choice F rationale
Observing the client for manifestations of a pneumothorax is important because bronchoscopy can occasionally cause a pneumothorax, especially if a biopsy is performed. Signs of pneumothorax include sudden chest pain, dyspnea, and decreased breath sounds on the affected side. .
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Correct Answer is C
Explanation
Choice A rationale
Metoclopramide is not used to suppress cough. It is primarily used to treat nausea, vomiting, and gastroparesis.
Choice B rationale
Metoclopramide does not have a primary effect on muscle relaxation. Its main action is to increase gastrointestinal motility.
Choice C rationale
Reduced nausea is a primary outcome for evaluating the effectiveness of metoclopramide. It is commonly prescribed to manage nausea and vomiting.
Choice D rationale
Metoclopramide is not typically used to decrease pain. Its primary indications are related to gastrointestinal symptoms.
Correct Answer is B
Explanation
Choice A rationale
Methimazole does not typically cause constipation. It is used to treat hyperthyroidism by inhibiting the production of thyroid hormones.
Choice B rationale
A sore throat can be a sign of agranulocytosis, a serious side effect of methimazole that involves a dangerously low white blood cell count. Patients are advised to contact their provider if they experience a sore throat.
Choice C rationale
While monitoring weight is important for patients with hyperthyroidism, it is not a specific instruction related to methimazole use.
Choice D rationale
Methimazole should be taken regularly as prescribed, not on an as-needed basis.