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
Expecting to have drowsiness while taking this medication is a common side effect of many seizure medications. However, it is not an indication of understanding the teaching about seizure medication management.
Choice B rationale
Taking an extra dose of the medication if a dose is missed is incorrect. Patients should not take an extra dose if they miss one. They should follow their healthcare provider’s instructions on what to do if a dose is missed.
Choice C rationale
Having blood checked to monitor the medication level indicates an understanding of the teaching. Monitoring blood levels of seizure medications is important to ensure therapeutic levels and avoid toxicity.
Choice D rationale
Taking the medication with an antacid to prevent indigestion is incorrect. Antacids can interfere with the absorption of some seizure medications.
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.