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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A halo device is a type of external fixation device that immobilizes the cervical spine after an injury or surgery. The device consists of a metal ring attached to four metal rods that are secured to a vest worn by the client. The device limits the movement of the head and neck, which can impair the client's ability to drive safely. The nurse should clarify with the provider if the client can operate a motor vehicle while wearing the halo device, as this may pose a risk for injury to the client and others on the road.

Placing a small pillow under the head when sleeping, increasing intake of fiber-rich foods, and taking tub baths instead of showers are all appropriate instructions for a client with a halo device

A. Deviation of the tongue from midline B. Loss of peripheral vision C. Disequilibrium with movement D. Inability to smell

Correct Answer is C

Explanation

The nurse should expect disequilibrium with movement if the client has impaired function of the vestibulocochlear nerve, as this nerve is responsible for hearing and balance. Deviation of the tongue from midline indicates impairment of the hypoglossal nerve (cranial nerve XII), loss of peripheral vision indicates impairment of the optic nerve (cranial nerve II), and inability to smell indicates impairment of the olfactory nerve (cranial nerve I).

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A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider?

Correct Answer is A

Explanation

A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?

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