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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should measure the client's blood pressure first, as sinus bradycardia can cause hypotension and decreased perfusion to vital organs. The nurse should assess the client's hemodynamic status and symptoms before initiating any interventions that may affect their heart rate or rhythm. The other options may be appropriate depending on the severity of the bradycardia and its underlying cause, but they are not the first priority.
Correct Answer is B
Explanation
A monthly calendar can help the client with Alzheimer's disease to orient to time and date and reduce confusion and anxiety. The nurse should encourage the family to use simple and clear reminders and cues to assist the client with daily activities and routines.
Covering electrical outlets with tape is not necessary and may pose a fire hazard. Keeping the client's bedroom dark at night may increase the risk of falls and injuries. A large-face clock may be helpful, but not as much as a calendar.
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