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
Rifampin is an antibiotic used to treat tuberculosis and other bacterial infections. It does not have a known interaction with St. John’s wort.
Choice B rationale
Furosemide is a diuretic used to treat fluid retention and high blood pressure. It does not have a known interaction with St. John’s wort.
Choice C rationale
Citalopram is a selective serotonin reuptake inhibitor (SSRI) used to treat depression. St. John’s wort can interact with SSRIs like citalopram, potentially leading to serotonin syndrome, a serious condition caused by excessive levels of serotonin in the brain.
Choice D rationale
Allopurinol is used to treat gout and kidney stones. It does not have a known interaction with St. John’s wort.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Peripheral edema is a common adverse effect of verapamil. It occurs due to the vasodilatory effects of the medication, which can cause fluid retention in the extremities.
Choice B rationale
Bradycardia is an adverse effect of verapamil. It occurs because verapamil slows down the heart rate by blocking calcium channels in the heart.
Choice C rationale
Constipation is a common adverse effect of verapamil. It occurs due to the medication’s effect on smooth muscle relaxation, which can slow down gastrointestinal motility.
Choice D rationale
Reports of blurred vision are not a common adverse effect of verapamil. Blurred vision is not typically associated with this medication.
Choice E rationale
Reports of insomnia are not a common adverse effect of verapamil. Insomnia is not typically associated with this medication.