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 A

Explanation

A. Air moves in and out of a wound in the chest wall.

In an open pneumothorax, also known as a sucking chest wound, there is a communication between the pleural space and the external environment through a wound in the chest wall. This allows air to move freely in and out of the pleural cavity during respiration. As a result, there is a loss of negative pressure within the pleural space, impairing lung expansion and leading to respiratory compromise. This condition is considered a medical emergency and requires prompt intervention to prevent tension pneumothorax and respiratory failure.

B. Air cannot pass freely into the thoracic cavity through a chest wound.

In an open pneumothorax, air can pass freely into the thoracic cavity through the chest wound. This communication between the external environment and the pleural space results in air movement in and out of the wound during respiration.

C. There are no audible sounds in an open pneumothorax.

In an open pneumothorax, there may be audible sounds, such as sucking or hissing sounds, particularly during inspiration. These sounds occur due to the movement of air in and out of the chest wound and can be indicative of the condition.

D. The air is trapped when it enters the cavity.

In an open pneumothorax, the air is not trapped when it enters the pleural cavity. Instead, air moves freely in and out of the wound in the chest wall, leading to respiratory compromise and potential progression to tension pneumothorax if left untreated.

A. "I'll rinse my mouth after taking this medication." B. "I'll use this medication when I get an asthma attack." C. "I'll take this medication once a day in the evening." D. "I'll decrease my sodium intake while I'm taking this medication."

Correct Answer is C

Explanation

A. "I'll rinse my mouth after taking this medication."

Montelukast is taken orally and is not associated with the risk of oral thrush or other mouth-related side effects that would require rinsing the mouth after administration. This action is more commonly associated with inhaled corticosteroids, not leukotriene receptor antagonists.

B. "I'll use this medication when I get an asthma attack."

Montelukast is not a rescue medication for asthma attacks. It is a long-term controller medication used to manage and prevent asthma symptoms, not to treat acute attacks. Short-acting bronchodilators such as albuterol are used for quick relief during asthma attacks.

C. "I'll take this medication once a day in the evening."

Montelukast is a leukotriene receptor antagonist commonly used to manage asthma. It is typically taken orally once daily, usually in the evening, to provide 24-hour control of asthma symptoms and improve lung function. Therefore, the statement indicating an understanding of the teaching is option C.

D. "I'll decrease my sodium intake while I'm taking this medication."

Montelukast is not known to affect sodium levels in the body or require any specific dietary modifications, such as decreasing sodium intake. Therefore, this statement is unrelated to the use of montelukast for asthma management

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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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Naxlex Comprehensive Predictor Exams

Which of the following is true regarding the physiology of an open pneumothorax?

Correct Answer is A

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Correct Answer is C

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