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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B"]
Explanation
A. 24-year-old woman with allergic rhinitis:
Likely safe to take an alpha-adrenergic decongestant as allergic rhinitis is a common indication for decongestant use in young, healthy individuals.
B. 18-year-old man with cold symptoms:
Likely safe to take an alpha-adrenergic decongestant as it's a common indication for decongestant use in young, healthy individuals.
C. 64-year-old woman with a history of heart disease:
Should avoid alpha-adrenergic decongestants due to the risk of increasing blood pressure and potentially worsening heart conditions.
D. 70-year-old woman with glaucoma:
Should avoid alpha-adrenergic decongestants due to the risk of exacerbating glaucoma by causing pupil dilation and increasing intraocular pressure.
E. 56-year-old man with prostatic hypertrophy:
Should avoid alpha-adrenergic decongestants due to the risk of worsening urinary symptoms caused by prostatic hypertrophy, such as urinary retention.
Correct Answer is B
Explanation
A. Prepare the client for endotracheal suctioning.
Endotracheal suctioning is a procedure used to clear secretions from the airway, which may be necessary in cases of respiratory distress. However, it is not the first action to take in this scenario. Before proceeding with suctioning, the nurse should first assess the client's respiratory status and implement interventions to improve ventilation and oxygenation.
B. Elevate the head of the bed.
This is the correct action to take first. Elevating the head of the bed helps improve the client's respiratory mechanics by allowing better lung expansion and reducing the work of breathing. It also helps alleviate symptoms of respiratory distress. This intervention should be implemented immediately to optimize the client's breathing.
C. Request a chest x-ray.
While a chest x-ray may provide valuable information about the client's respiratory status, it is not the first action to take in this acute situation. Chest x-rays require time to be performed and interpreted, which may delay necessary interventions to address the client's immediate respiratory distress.
D. Obtain a sputum culture.
Obtaining a sputum culture may be indicated to identify the underlying cause of respiratory distress, such as infection. However, it is not the first action to take when the client is experiencing acute respiratory distress. The priority is to implement interventions to improve ventilation and oxygenation to stabilize the client's condition.
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