A nurse is caring for a client following a bronchoscopy with moderate sedation. Which of the following actions should the nurse take? (Select all that apply.)

Assess the client’s gag reflex before offering oral intake.

Listen to the client’s breath sounds.

Monitor the client’s oxygen saturation.

Monitor the client for manifestations of bleeding.

Assess the client’s puncture site.

Observe the client for manifestations of a pneumothorax.

Answer and Explanation

Correct Answer : A,B,C,D,F

Choice A rationale
Assessing the client’s gag reflex before offering oral intake is essential to prevent aspiration. The gag reflex may be diminished after moderate sedation and the use of local anesthetics during bronchoscopy.
Choice B rationale
Listening to the client’s breath sounds is important to detect any abnormalities, such as wheezing, crackles, or decreased breath sounds, which could indicate complications like bronchospasm or pneumothorax.
Choice C rationale
Monitoring the client’s oxygen saturation is crucial to ensure adequate oxygenation and detect any signs of respiratory distress or hypoxemia following the procedure.
Choice D rationale
Monitoring the client for manifestations of bleeding is necessary because bronchoscopy can cause trauma to the airways, leading to bleeding. Signs of bleeding may include hemoptysis or a drop in hemoglobin levels.
Choice E rationale
Assessing the client’s puncture site is not applicable in this context, as bronchoscopy does not involve a puncture site. This option is incorrect.
Choice F rationale
Observing the client for manifestations of a pneumothorax is important because bronchoscopy can occasionally cause a pneumothorax, especially if a biopsy is performed. Signs of pneumothorax include sudden chest pain, dyspnea, and decreased breath sounds on the affected side.

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Correct Answer is A

Explanation

Choice A rationale
Naloxone is an opioid antagonist that rapidly reverses the effects of opioid overdose, including respiratory depression. It binds to opioid receptors and displaces the opioid molecules, reversing their effects.
Choice B rationale
Bisacodyl is a stimulant laxative used to treat constipation. It does not have any effect on opioid-induced respiratory depression.
Choice C rationale
Flumazenil is a benzodiazepine antagonist used to reverse the effects of benzodiazepines, not opioids. It is not effective in treating opioid-induced respiratory depression.
Choice D rationale
Pentazocine is an opioid agonist-antagonist used for pain relief. It does not reverse opioid-induced respiratory depression and can potentially worsen the condition.

A. Repeat up to four doses until pain is relieved. B. Store unused tablets at room temperature. C. Take two tablets at the onset of pain. D. Take the medication two hours prior to exercise.

Correct Answer is B

Explanation

Choice A rationale
Repeating up to four doses until pain is relieved is incorrect. The correct instruction is to take one tablet at the onset of pain and repeat every 5 minutes if needed, up to a maximum of three tablets in 15 minutes.
Choice B rationale
Storing unused tablets at room temperature is correct. Nitroglycerin tablets should be stored in their original container at room temperature, away from moisture and heat.
Choice C rationale
Taking two tablets at the onset of pain is incorrect. The correct instruction is to take one tablet at the onset of pain and repeat every 5 minutes if needed, up to a maximum of three tablets in 15 minutes.
Choice D rationale
Taking the medication two hours prior to exercise is incorrect. Nitroglycerin should be taken 5 to 10 minutes before an activity that may cause chest pain.

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A nurse is caring for a client following a bronchoscopy with moderate sedation. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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