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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.)

A.

Assess the client’s gag reflex before offering oral intake.

B.

Listen to the client’s breath sounds.

C.

Monitor the client’s oxygen saturation.

D.

Monitor the client for manifestations of bleeding.

E.

Assess the client’s puncture site.

F.

Observe the client for manifestations of a pneumothorax.

Question Solution

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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View Related questions

Correct Answer is D

Explanation

Choice A rationale

CBC results are not directly related to the initiation of alendronate therapy.

Choice B rationale

Family history of colon cancer is not relevant to alendronate therapy.

Choice C rationale

Thyroid function is not directly related to alendronate therapy.

Choice D rationale

Pregnancy status should be assessed as alendronate is contraindicated during pregnancy.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale

Contacting the provider is essential to inform them of the error and receive further instructions on managing the client’s condition.

Choice B rationale

Reporting the error to the charge nurse is necessary for proper documentation and to ensure that corrective actions are taken to prevent future errors.

Choice C rationale

Incident reports should not be placed in the client’s chart. They are for internal use to improve safety and quality of care.

Choice D rationale

Auscultating the client’s lungs is important to check for signs of fluid overload, such as crackles or wheezing.

Choice E rationale

Checking for peripheral edema helps assess the extent of fluid overload and its impact on the client’s condition.

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