A nurse is caring for a client who has just had a bronchoscopy. Which of the following actions should the nurse take?
Withhold food and liquids until the client's gag reflex returns.
Irrigate the client's throat every 4 hr.
Have the client refrain from talking for 24 hr.
Suction the client's oropharynx frequently.
The Correct Answer is A
A. Withhold food and liquids until the client's gag reflex returns.
This is the correct action. After a bronchoscopy, the client's throat may be numb or irritated from the procedure, which can temporarily impair the gag reflex. Withholding food and liquids until the gag reflex returns reduces the risk of aspiration, where food or liquid enters the airway instead of the stomach. Aspiration can lead to pneumonia and other serious complications. Therefore, it's essential to assess the client's gag reflex before allowing them to eat or drink.
B. Irrigate the client's throat every 4 hours.
This action is not necessary and may even be harmful. Irrigating the client's throat every 4 hours could further irritate the throat and increase discomfort for the client. Unless specifically ordered by the healthcare provider for a specific reason, such as to remove secretions or debris, routine irrigation of the throat is not recommended after a bronchoscopy.
C. Have the client refrain from talking for 24 hours.
There is typically no need for the client to refrain from talking for 24 hours after a bronchoscopy. While the client may experience some throat discomfort and hoarseness, restricting talking for such an extended period is unnecessary and may cause undue stress or anxiety for the client. Unless specifically instructed by the healthcare provider for a valid reason, such as to allow vocal cord healing, there is no need to restrict talking for such a long duration.
D. Suction the client's oropharynx frequently.
Frequent suctioning of the client's oropharynx is not indicated unless there is a specific medical reason to do so. Excessive suctioning can cause trauma to the mucous membranes, increase the risk of infection, and exacerbate throat irritation. The decision to suction should be based on clinical assessment, such as evidence of secretions or if the client is having difficulty clearing their airway, rather than being performed routinely.
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Related Questions
Correct Answer is D
Explanation
A. Place tissue soiled with respiratory secretions in a paper bag for later disposal:
This instruction is not accurate or recommended for managing tissue soiled with respiratory secretions, particularly in the context of tuberculosis (TB) infection. TB is transmitted through the air via respiratory droplets, so proper disposal of contaminated materials is crucial to prevent the spread of the infection. Instead of placing tissue in a paper bag, it should be disposed of in a sealed plastic bag to minimize the risk of transmission. Additionally, individuals with TB should be instructed on proper respiratory hygiene practices, such as covering their mouth and nose with a tissue or their elbow when coughing or sneezing, to prevent the spread of infectious droplets.
B. Provide samples for sputum cultures every 6 weeks:
Sputum cultures are an essential component of monitoring and managing tuberculosis (TB) treatment. However, obtaining samples every 6 weeks is not frequent enough, especially during the initial phase of treatment. In the early stages of TB treatment, sputum cultures are typically obtained more frequently, often weekly or biweekly, to monitor the response to treatment, assess for drug resistance, and ensure treatment effectiveness. As treatment progresses and the patient's condition stabilizes, the frequency of sputum cultures may be adjusted based on clinical judgment and guidelines.
C. Consume alcohol in moderation while taking antituberculosis medications:
Alcohol consumption is generally discouraged while taking antituberculosis medications. Some antituberculosis drugs, such as isoniazid and rifampin, can interact with alcohol and cause adverse effects, such as liver toxicity or drug metabolism issues. Therefore, individuals undergoing treatment for tuberculosis should be advised to abstain from alcohol consumption or limit it to a minimum to avoid potential complications. Providing instructions on alcohol consumption is an important aspect of tuberculosis management and medication adherence.
D. Wear a mask while out or around crowds of people:
This instruction is crucial for individuals with pulmonary tuberculosis to prevent the spread of the infection to others. Tuberculosis is transmitted through the air via respiratory droplets, particularly when an infected person coughs, sneezes, or talks. Wearing a mask while out or in crowded settings helps reduce the risk of transmitting infectious droplets to others and is an important infection control measure. It is especially important during the early stages of treatment when the individual is still infectious and shedding bacteria. Proper mask use, along with other respiratory hygiene practices, can help protect both the individual with tuberculosis and those around them from the spread of infection.
Correct Answer is A
Explanation
A. Lower oxygen saturations of 93% to 94%
In an older adult client with a pneumothorax, the nurse could expect to observe lower oxygen saturations of 93% to 94%. A pneumothorax involves the accumulation of air in the pleural space, which can compress the lung and impair gas exchange, leading to hypoxemia (low blood oxygen levels). Decreased oxygen saturations would be a common finding in this condition.
B. Higher oxygen saturations of 98% to 99%
Higher oxygen saturations would be less likely in a client with a pneumothorax due to impaired gas exchange resulting from lung compression. Oxygen saturations are more likely to be lower in this condition, as indicated in option A.
C. Lower energy expenditure
While a pneumothorax may cause discomfort and dyspnea, which could potentially decrease energy expenditure due to reduced activity levels, it is not a direct physiological effect of the condition. Energy expenditure would depend on various factors, including the severity of symptoms and the individual's overall health status.
D. Increased lung capacity
A pneumothorax typically results in a decrease in lung capacity rather than an increase. The accumulation of air in the pleural space causes partial or complete collapse of the affected lung, reducing its ability to expand and decreasing overall lung capacity. Therefore, increased lung capacity would not be expected in a client with a pneumothorax.
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