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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 B

Explanation

Choice A rationale

Decreased excretion of urine sodium is not an expected therapeutic effect of bumetanide. Bumetanide is a loop diuretic that works by inhibiting the reabsorption of sodium and chloride in the ascending loop of Henle, leading to increased excretion of sodium and water.

Choice B rationale

Increased urinary output is the expected therapeutic effect of bumetanide. As a potent loop diuretic, bumetanide increases the excretion of water and electrolytes, which helps reduce fluid accumulation in conditions like ascites.

Choice C rationale

Decreased serum glucose is not associated with bumetanide. Bumetanide primarily affects fluid and electrolyte balance and does not have a significant impact on blood glucose levels.

Choice D rationale

Increased blood pressure is not an expected effect of bumetanide. On the contrary, bumetanide can help lower blood pressure by reducing fluid volume and decreasing the workload on the heart.

Correct Answer is A

Explanation

Choice A rationale

A neutrophil count of 650/mm³ is significantly lower than the normal range (2,500 to 8,000/mm³) and indicates neutropenia, which is a known adverse effect of zidovudine. Neutropenia increases the risk of infections and requires close monitoring and potential dose adjustment or discontinuation of the medication.

Choice B rationale

A platelet count of 450,000/mm³ is slightly above the normal range (150,000 to 400,000/mm³) but is not typically associated with zidovudine toxicity. Zidovudine is more commonly associated with bone marrow suppression leading to anemia and neutropenia rather than thrombocytosis.

Choice C rationale

An Hgb level of 17 g/dL is above the normal range for females (12 to 16 g/dL) but is not a common adverse effect of zidovudine. Zidovudine is more likely to cause anemia, leading to lower hemoglobin levels rather than elevated levels.

Choice D rationale

A creatinine level of 1.5 mg/dL is within the upper limit of the normal range (0.5 to 1 mg/dL) and is not a typical adverse effect of zidovudine. Zidovudine primarily affects the bone marrow and does not have a significant impact on renal function.

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