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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Perform breast self-examinations during the middle of your cycle.": The best time for premenopausal clients to perform a breast self-exam is 5-7 days after the menstrual period ends, when hormonal fluctuations are minimal, and the breasts are less tender.
B. "Perform breast self-examinations while lying on your side.": The recommended position for self-examination is lying flat with the arm on the side being examined raised above the head, as this spreads the breast tissue more evenly.
C. "Use small, circular motions, working vertically up and down across the breast.": The vertical strip method, using small circular motions, is the recommended technique for thorough breast self-examination. It ensures that all breast tissue is palpated, including the axillary area.
D. "Use the palm of your hand to detect the presence of any large masses under the skin.": The pads of the fingers, not the palm, are used to palpate the breast for lumps or abnormalities.
Correct Answer is ["D","E","F"]
Explanation
A. Fluid intake: While fluid balance is important, there is no specific information indicating that changes in fluid intake are an indicator of the client’s condition improving in this context.
B. Temperature: The client's temperature has increased from 38.3°C (101°F) on Day 1 to 39.2°C (102.5°F) on Day 4. An increase in temperature indicates a possible infection or ongoing inflammation and does not suggest an improvement in the client’s condition.
C. Wound findings: There are no documented wound findings in the given notes. Thus, wound findings are not applicable in determining whether the client’s condition has improved in this scenario.
D. Pain level: The client's pain level has decreased from 7 to 3, indicating improvement.
E. Report of nausea: The client reports feeling less nauseous and has not vomited since yesterday, which is a sign of improvement.
F. Bowel sounds: The bowel sounds are more regular and less high-pitched, suggesting improvement in gastrointestinal function.
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