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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Prone with arms raised over the head.
This position involves lying face down with the arms raised over the head. It is not appropriate for thoracentesis because it does not provide easy access to the thoracic cavity, and it may compress the chest, making it difficult for the client to breathe comfortably during the procedure.
B. Sitting, leaning forward over the bedside table.
This is the correct choice. For thoracentesis, the client should be positioned sitting upright and leaning forward over the bedside table or supported by pillows. This position allows better access to the thoracic cavity and facilitates the removal of pleural fluid. Leaning forward also helps to open up the intercostal spaces, making it easier for the healthcare provider to insert the needle into the appropriate space between the ribs.
C. High Fowler's position.
The High Fowler's position involves the client sitting upright with the head of the bed elevated at a 90-degree angle. While this position may be used for other respiratory procedures or for comfort, it is not the optimal position for thoracentesis. It does not provide the same degree of access to the thoracic cavity as the sitting position with forward leaning.
D. Side-lying with knees drawn up to the chest.
This position involves lying on one side with the knees drawn up to the chest. It is not appropriate for thoracentesis because it does not provide access to the thoracic cavity, and it may obstruct the procedure. Additionally, this position may not be comfortable for the client during the procedure.
Correct Answer is B
Explanation
A. Assign health care personnel to nondirect care activities for 24 hr after developing influenza symptoms.
While it's important for healthcare personnel to stay home when they have influenza symptoms to prevent transmission to residents and coworkers, restricting them to nondirect care activities for only 24 hours may not be sufficient. Healthcare personnel with influenza symptoms should follow institutional policies regarding sick leave and clearance to return to work, which typically involve staying home until they are no longer contagious.
B. Place restrictions on visitation.
During an influenza outbreak in a long-term care facility, it's crucial to include interventions to prevent further spread of the virus. Placing restrictions on visitation helps reduce the risk of introducing the virus from outside sources into the facility. Visitors may inadvertently bring the influenza virus with them, potentially exposing vulnerable residents and staff members.
C. Implement airborne precautions for clients who have influenza.
Influenza is primarily transmitted through respiratory droplets rather than through airborne transmission. Airborne precautions are not typically necessary for managing influenza in a long-term care facility. Standard precautions, including hand hygiene, respiratory hygiene/cough etiquette, and use of personal protective equipment, are sufficient for preventing transmission.
D. Provide prophylactic antibiotics for clients who have been exposed to influenza.
Influenza is a viral infection and is not treated with antibiotics. Prophylactic antibiotics are not indicated for preventing influenza. Antiviral medications may be used for prophylaxis in certain high-risk individuals or in outbreak settings, but their use should be based on recommendations from public health authorities and healthcare providers, not blanket administration to all exposed individuals.
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