A nurse is caring for a patient who has just returned to the unit following a bronchoscopy and requests coffee.
The nurse assesses that it is safe for the patient to resume oral liquids when which of the following behaviors is demonstrated?
The patient can drink water through a straw without choking.
The patient has intact cough and swallowing reflexes.
The patient has clear breath sounds upon auscultation.
The patient reports that they are not experiencing a sore throat.
The Correct Answer is B
Choice A rationale
While being able to drink water through a straw without choking is a positive sign, it is not the primary indicator that a patient can safely resume oral liquids after a bronchoscopy. The primary indicator is the return of the patient’s cough and swallowing reflexes.
Choice B rationale
The patient has intact cough and swallowing reflexes is the primary indicator that a patient can safely resume oral liquids after a bronchoscopy. These reflexes are essential for preventing aspiration, which can lead to pneumonia.
Choice C rationale
While clear breath sounds upon auscultation are a positive sign, they are not the primary indicator that a patient can safely resume oral liquids after a bronchoscopy. The primary indicator is the return of the patient’s cough and swallowing reflexes.
Choice D rationale
The absence of a sore throat is not the primary indicator that a patient can safely resume oral liquids after a bronchoscopy. The primary indicator is the return of the patient’s cough and swallowing reflexes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Restlessness in a client with a tracheostomy could indicate respiratory distress or hypoxia. It’s important for the nurse to further assess the client’s vital signs, oxygen saturation, and overall appearance.
Choice B rationale
A SaO2 of 92% on 40% humidified oxygen via tracheostomy collar is within the acceptable range for a client with a tracheostomy. However, it’s important to consider the client’s baseline SaO2 and any changes in their condition.
Choice C rationale
Scattered rhonchi throughout the lung fields could indicate secretions in the airways. However, this finding alone does not necessarily indicate a problem with the tracheostomy.
Choice D rationale
Suctioning of thin clear secretions from a tracheostomy is a routine part of tracheostomy care. This finding does not necessarily indicate a problem with the tracheostomy.
Correct Answer is B
Explanation
Choice A rationale
A chocolate milkshake may be soothing, but it is not the best choice for a patient with bacterial pharyngitis due to its high sugar content, which can promote bacterial growth.
Choice B rationale
Chicken noodle soup is a good choice as it is soothing, easy to swallow, and provides necessary nutrients.
Choice C rationale
Vanilla ice cream, while soothing, is not the best choice due to its high sugar content.
Choice D rationale
Fruit-flavored popsicles, while soothing, are not the best choice due to their high sugar content.
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