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 D
Explanation
Choice A rationale
Phenytoin is an anticonvulsant used to control seizures and is not indicated for the treatment of adrenal insufficiency.
Choice B rationale
Calcitonin is used to treat conditions like osteoporosis and hypercalcemia, not adrenal insufficiency.
Choice C rationale
Buspirone is an anxiolytic used to treat anxiety disorders and is not used for adrenal insufficiency.
Choice D rationale
Fludrocortisone is a synthetic corticosteroid that is used to replace aldosterone in patients with adrenal insufficiency. It helps maintain sodium balance and blood pressure.
Correct Answer is C
Explanation
Choice A rationale
Ipratropium inhalers can potentially increase heart rate and blood pressure, but this is not a common side effect. The concern about high blood pressure is valid but not as critical as an allergy to atropine.
Choice B rationale
Using albuterol with ipratropium is common practice for managing bronchospasm. There is no contraindication for using both medications together.
Choice C rationale
An allergy to atropine is significant because ipratropium is chemically related to atropine. This could lead to a severe allergic reaction.
Choice D rationale
There are no known interactions between ipratropium and alcohol. However, it is always best to consult with a healthcare provider regarding alcohol consumption while on medication.