A nurse is assisting with the care of a client who had a bronchoscopy 12 hr ago. Which of the following findings should the nurse report to the provider?

The client has inspiratory stridor

The client reports a sore throat.

The client's sputum has streaks of blood.

The client's temperature is 38.6" C/101.4 F

Answer and Explanation

The Correct Answer is A

A. The client has an inspiratory stridor. Inspiratory stridor indicates airway obstruction or laryngeal edema, a potentially life-threatening complication following a bronchoscopy that requires immediate intervention.
B. The client reports a sore throat: A sore throat is common after bronchoscopy due to irritation from the scope. This does not require reporting.
C. The client’s sputum has streaks of blood: Small amounts of blood in sputum are expected due to minor mucosal trauma.
D. The client’s temperature is 38.6°C (101.4°F): Mild fever can occur post-procedure due to inflammation but should only be reported if it persists or other infection signs develop.

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Correct Answer is D

Explanation

A. Soreness at the incision site: Mild soreness is an expected postoperative finding.
B. Serosanguineous drainage on the dressing: This type of drainage is typical after surgery and not concerning unless it becomes excessive.
C. Report of a sore throat: A sore throat is expected due to intubation during anesthesia and does not indicate a complication.
D. Tingling of the fingers: Tingling of the fingers suggests hypocalcemia due to potential damage to the parathyroid glands during surgery. This is a serious complication and requires immediate evaluation.

A. Clamp the tube for 30 min every 8 hr. B. Pin the tubing to the client's bed sheets. C. Monitor for at least 150 mL of drainage every hour. D. Replace the unit when the drainage chamber is full.

Correct Answer is D

Explanation

A. Clamp the tube for 30 min every 8 hr: Clamping a chest tube increases the risk of tension pneumothorax and is contraindicated unless ordered by a provider.
B. Pin the tubing to the client's bed sheets: Pinning can cause disconnection or kinking of the tubing, leading to drainage issues.
C. Monitor for at least 150 mL of drainage every hour: Drainage greater than 100 mL/hour, especially after the first hour, should be reported as it may indicate hemorrhage.
D. Replace the unit when the drainage chamber is full. A full drainage chamber must be replaced to ensure the system functions properly and prevents complications like backflow.

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A nurse is assisting with the care of a client who had a bronchoscopy 12 hr ago. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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