A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?
Have the client refrain from talking for 24 hr.
Withhold food and liquids until the client's gag reflex returns.
Irrigate the client's throat every 4 hr.
Suction the client's oropharynx frequently.
The Correct Answer is B
A. Have the client refrain from talking for 24 hr.: This is unnecessary; the client may talk once the effects of the local anesthetic wear off, typically within an hour or two after the procedure.
B. Withhold food and liquids until the client's gag reflex returns: This is the most important action to prevent aspiration. After a bronchoscopy, the throat is anesthetized, and eating or drinking before the gag reflex returns increases the risk of aspiration.
C. Irrigate the client's throat every 4 hr.: This is not a routine post-procedure intervention and could be uncomfortable for the client.
D. Suction the client's oropharynx frequently: Suctioning should only be performed if the client has difficulty clearing secretions. There is no routine need for frequent suctioning after a bronchoscopy unless clinically indicated.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Fatigue: While fatigue can occur in lung cancer patients, it is not the most common symptom. Fatigue is more of a generalized symptom that can be seen in many diseases, not specific to lung cancer.
B. Hoarseness: Hoarseness can be a symptom of lung cancer, particularly if a tumor is affecting the laryngeal nerves. However, it is less common than a persistent cough and is not usually the initial symptom.
C. Anorexia: Anorexia (loss of appetite) can occur in patients with advanced cancer, including lung cancer, but it is not the most common presenting symptom. Weight loss due to anorexia is more common in later stages.
D. Persistent cough: This is the correct answer. A persistent cough is the most common symptom of lung cancer, especially in the early stages. The cough may be dry or productive and is often overlooked or mistaken for a chronic respiratory condition. It is frequently one of the first signs that leads to further investigation and diagnosis.
Correct Answer is C
Explanation
A. Blistering burns are not a typical side effect of radiation therapy for laryngeal cancer. Radiation burns can occur on the skin, but they are more likely to cause irritation and redness rather than blistering burns, especially in the case of internal radiation targeting the larynx.
B. Diarrhea is a common side effect of radiation therapy when the abdominal or pelvic areas are treated, but it is not typically associated with radiation therapy to the larynx.
C. Dry mouth (xerostomia) is a common side effect of radiation therapy for laryngeal cancer, as the salivary glands may be affected by the radiation. This results in reduced saliva production, leading to a dry mouth.
D. Nausea is not a typical side effect of radiation therapy for laryngeal cancer specifically, though it may occur if other areas (such as the stomach) are being treated. Nausea is more commonly associated with chemotherapy.
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