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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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Correct Answer is B

Explanation

Choice A rationale

Crushing tadalafil is not recommended as it can alter the medication’s effectiveness and absorption. Tadalafil should be taken whole to ensure proper dosage and efficacy.

Choice B rationale

Tadalafil can decrease blood pressure by relaxing blood vessels, which allows for increased blood flow. This is a known effect of phosphodiesterase type 5 (PDE5) inhibitors like tadalafil.

Choice C rationale

Tadalafil should not be taken more than once a day. Taking it twice a day can increase the risk of side effects and is not recommended.

Choice D rationale

The effects of tadalafil can last up to 36 hours, not just 4 hours. This prolonged duration is one of the reasons it is preferred by some patients.

Correct Answer is A

Explanation

Choice A rationale

Asking the client to describe their concerns allows the nurse to understand the client’s perspective and address any misconceptions or fears they may have about the influenza immunization.

Choice B rationale

Contacting the provider is important but should be done after understanding the client’s concerns to provide a comprehensive report.

Choice C rationale

Providing education is essential but should follow understanding the client’s specific concerns to tailor the information effectively.

Choice D rationale

Documenting the refusal is necessary but should be done after addressing the client’s concerns and providing education.

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