A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?
Check the client's gag reflex.
Inform the client they might experience a low-grade fever.
Provide the client with sips of water.
Instruct the client to report bleeding.
The Correct Answer is A
The nurse should assess the client's gag reflex before allowing oral intake to prevent aspiration. The client's throat may be numb after a bronchoscopy, which is a procedure that uses a thin tube with a camera and light to examine the lungs and airways . The other actions are important but not the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Sinus bradycardia is a type of cardiac arrhythmia characterized by a heart rate lower than 60 beats per minute in adults, or below the normal range for age in children. It can be diagnosed by an electrocardiogram (ECG) that shows regular P waves with constant morphology preceding every QRS complex, and positive in lead II.
Correct Answer is D
Explanation
The client has hypokalemia, which is a low level of potassium in the blood. Hypokalemia can cause cardiac arrhythmias, which can be life-threatening. The nurse should initiate cardiac monitoring first to assess the client's heart rhythm and rate, and intervene if any abnormalities are detected. Administering an IV potassium drip is an appropriate intervention for hypokalemia, but it is not the first priority. Listening to the client's bowel sounds and checking the client's hand grasps are also relevant assessments for hypokalemia, as it can cause decreased bowel motility and muscle weakness, but they are not as urgent as cardiac monitoring.
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