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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Saving the sputum specimen in a clean container.

While it is important to collect the sputum specimen in a clean, sterile container, simply saving the specimen in a clean container is not sufficient. The nurse needs to actively collect the sputum specimen from the client using proper technique to ensure that it is not contaminated and is suitable for laboratory analysis.

B. Collecting the sputum specimen after a meal.

Collecting a sputum specimen after a meal is not recommended, as it can increase the likelihood of contamination with food particles. It's preferable to collect the specimen before meals or at least 1-2 hours after eating to minimize the risk of contamination and ensure the integrity of the specimen.

C. Rinse the client's mouth before collecting the specimen.

When obtaining a sputum specimen from a client, it's important for the nurse to plan to rinse the client's mouth before collecting the specimen. Rinsing the mouth with water helps to clear any food particles or debris from the oral cavity, ensuring that the sputum sample collected is not contaminated with saliva or food particles. This improves the quality and accuracy of the specimen for laboratory analysis.

D. Obtaining the specimen from the client in the evening.

The timing of specimen collection is not necessarily restricted to the evening. The timing may vary depending on the client's condition and the healthcare provider's orders. It's important to follow the healthcare provider's instructions regarding the timing of specimen collection, which may be based on factors such as the client's symptoms and the diagnostic requirements.

A. Administer IV morphine. B. Begin oxygen therapy. C. Start an IV infusion of lactated Ringer's. D. Initiate cardiac monitoring.

Correct Answer is B

Explanation

A. Administer IV morphine.

IV morphine may be indicated to relieve pain and anxiety associated with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

B. Begin oxygen therapy.

The priority intervention for a client who develops a pulmonary embolism is to begin oxygen therapy. Pulmonary embolism (PE) is a life-threatening condition characterized by a blockage in one or more of the pulmonary arteries, usually due to a blood clot. This blockage can lead to impaired gas exchange and decreased oxygenation of the blood, resulting in hypoxemia (low blood oxygen levels) and potentially leading to respiratory failure. Administering oxygen therapy promptly helps to improve oxygenation and support vital organ function. Therefore, it is the priority intervention to address the immediate respiratory distress associated with a pulmonary embolism.

C. Start an IV infusion of lactated Ringer's.

Intravenous fluid administration may be necessary to maintain hemodynamic stability and support perfusion in a client with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

D. Initiate cardiac monitoring.

Cardiac monitoring is important to assess for signs of cardiac compromise or dysrhythmias associated with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

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A nurse is caring for a client who has just had a bronchoscopy. Which of the following actions should the nurse take?

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Correct Answer is C

Explanation

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Correct Answer is B

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