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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

Folic acid is not primarily used to stimulate the immune system. Its main role is in the production of red blood cells and DNA synthesis.

Choice B rationale

Folic acid does not increase the absorption of other medications. It is used to prevent and treat folate deficiency.

Choice C rationale

Folic acid is not used to treat benign prostatic hyperplasia. It is important for cell growth and the production of red blood cells.

Choice D rationale

Folic acid is crucial for the building of blood cells and is especially important during periods of rapid cell division, such as pregnancy.

Correct Answer is D

Explanation

Choice A rationale

Asthma is not a contraindication for sumatriptan. Sumatriptan is a selective serotonin receptor agonist used to treat migraines by constricting blood vessels in the brain. It does not have a significant impact on respiratory conditions like asthma.

Choice B rationale

Kidney disease is not a contraindication for sumatriptan. However, caution is advised when using sumatriptan in patients with severe renal impairment due to potential accumulation of the drug and its metabolites.

Choice C rationale

Rheumatoid arthritis is not a contraindication for sumatriptan. Sumatriptan’s mechanism of action does not interfere with the inflammatory processes involved in rheumatoid arthritis.

Choice D rationale

Coronary artery disease (CAD) is a contraindication for sumatriptan. Sumatriptan can cause vasoconstriction of coronary arteries, which can exacerbate CAD and increase the risk of myocardial infarction or other cardiac events.

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