A nurse is gathering information from a patient who has undergone a bronchoscopy. Which of the following observations should the nurse report to the healthcare provider?
Sore throat
Presence of gag reflex
Blood pressure 110/88 mm Hg
Facial edema
The Correct Answer is D
A. Sore throat: A sore throat is a common side effect following a bronchoscopy due to irritation of the airway. It is typically expected and does not indicate a serious complication.
B. Presence of gag reflex: The return of the gag reflex after a bronchoscopy is a normal finding. It indicates that the protective airway reflexes are intact, which is a positive sign.
C. Blood pressure 110/88 mm Hg: Although the diastolic pressure is a bit high, this blood pressure reading is generally acceptable post-procedure and is not typically concerning in the context of a bronchoscopy.
D. Facial edema: Facial edema is not a normal finding following a bronchoscopy. It may indicate an allergic reaction, adverse response to medications used during the procedure, or a complication such as airway edema. This finding should be reported immediately to the healthcare provider as it could signal a potentially serious condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Choosing fortified foods containing vitamin B2 is a good practice. Vitamin B2, also known as riboflavin, is important for energy production and cellular function, and older adults may need more of this nutrient.
Choice B rationale
Decreasing fluid intake is not generally recommended for older adults. Adequate hydration is important for many body functions, including maintaining blood volume and preventing constipation.
Choice C rationale
Limiting intake of plant-based foods is not a healthy practice. Plant-based foods are rich in fiber, vitamins, and minerals, and they can help reduce the risk of chronic diseases.
Choice D rationale
Decreasing daily intake of protein is not generally recommended for older adults. Protein is essential for maintaining muscle mass, which tends to decrease with age.
Correct Answer is B
Explanation
Choice A rationale
Wearing a surgical mask when entering the patient’s room is a standard precaution for all healthcare workers, but it may not be sufficient for a patient with severe coughing, night sweats, and blood in the sputum. These symptoms could indicate a contagious disease such as tuberculosis, which requires airborne precautions.
Choice B rationale
Placing the patient in a negative-pressure airflow room is the correct action. This type of room is used for patients who may have airborne infectious diseases. The negative pressure prevents airborne pathogens from escaping the room and infecting others.
Choice C rationale
Keeping a container for soiled linens outside the patient’s door is not the most appropriate action in this situation. While it is important to handle soiled linens properly to prevent the spread of infection, it does not address the potential airborne transmission of pathogens.
Choice D rationale
Remaining within 3 feet of the patient is not the most appropriate action in this situation. If the patient has an airborne infectious disease, healthcare workers should minimize close contact to prevent exposure.
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