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
An incentive spirometer is a device that helps improve lung function by encouraging deep breathing and preventing atelectasis (collapse of alveoli) after surgery or prolonged bed rest. The client should position the mouthpiece firmly in their mouth, inhale deeply and slowly through the mouthpiece until the indicator reaches the desired level, hold their breath for 3 to 5 seconds, and then exhale normally through their nose or mouth.
Exhaling slowly through pursed lips or placing hands on the upper abdomen are techniques that can help with dyspnea (shortness of breath), but are not part of using an incentive spirometer. Positioning the mouthpiece 2.5 cm.
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.
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