A client who had a bronchoscopy 2 hours ago asks for a drink of water. What action would the nurse take initially to assure client safety?
Assess the client’s gag reflex before giving any food or water.
Provide the client with ice chips instead of a drink of water.
Contact the primary healthcare provider and get the appropriate orders.
Let the client have a small sip to evaluate the ability to swallow.
The Correct Answer is A
Choice A Reason:
Assessing the client’s gag reflex before giving any food or water is crucial after a bronchoscopy. The procedure involves the use of local anesthesia to numb the throat, which can impair the gag reflex and increase the risk of aspiration. Ensuring that the gag reflex has returned before allowing the client to eat or drink helps prevent choking and aspiration, which are serious complications.
Choice B Reason:
Providing the client with ice chips instead of a drink of water is not the best initial action. While ice chips may seem like a safer option, they still pose a risk of aspiration if the gag reflex has not fully returned. The priority is to first assess the gag reflex to ensure the client can safely swallow.
Choice C Reason:
Contacting the primary healthcare provider and getting the appropriate orders is not necessary as the first action. The nurse can independently assess the gag reflex, which is a standard nursing practice after procedures involving throat anesthesia. If there are concerns after the assessment, then contacting the healthcare provider would be appropriate.
Choice D Reason:
Letting the client have a small sip to evaluate the ability to swallow is not safe without first assessing the gag reflex. This approach could lead to aspiration if the gag reflex has not returned. The initial step should always be to assess the gag reflex to ensure the client can safely swallow liquids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: A buffalo hump is a characteristic sign of Cushing’s syndrome. It refers to the accumulation of fat on the back of the neck and shoulders. This symptom occurs due to the excessive production of cortisol, which leads to abnormal fat distribution in the body.
Choice B reason: Moon face is another hallmark of Cushing’s syndrome. It describes the rounding and fullness of the face, which results from fat deposits. This symptom is also caused by prolonged exposure to high levels of cortisol.
Choice C reason: Hypertension, or high blood pressure, is commonly associated with Cushing’s syndrome. Cortisol increases blood pressure by enhancing the sensitivity of blood vessels to catecholamines and by promoting sodium and water retention.
Choice D reason: Purple striations, or stretch marks, are often seen in individuals with Cushing’s syndrome. These marks typically appear on the abdomen, thighs, breasts, and arms. They result from the thinning of the skin and the breakdown of collagen due to elevated cortisol levels.
Choice E reason: Tremors are not typically associated with Cushing’s syndrome. While Cushing’s syndrome can cause a variety of symptoms, tremors are more commonly linked to other conditions such as hyperthyroidism or neurological disorders.
Correct Answer is ["B","C","E"]
Explanation
Choice A Reason:
Excessive salivation, also known as water brash, can occur in some cases of GERD, but it is not one of the most common symptoms. Water brash happens when the body produces extra saliva to neutralize the acid in the esophagus. While it can be associated with GERD, it is not as prevalent as other symptoms like heartburn or regurgitation.
Choice B Reason:
Dyspepsia, or indigestion, is a common symptom of GERD. It includes discomfort or pain in the upper abdomen, bloating, and nausea. Dyspepsia occurs because the stomach acid irritates the lining of the esophagus and stomach, leading to these uncomfortable sensations. Therefore, dyspepsia is a typical finding in patients with GERD.
Choice C Reason:
Regurgitation is a hallmark symptom of GERD. It involves the backflow of stomach contents into the esophagus and sometimes into the mouth, causing a sour or bitter taste. This symptom is due to the weakening or relaxation of the lower esophageal sphincter, which allows stomach acid to escape into the esophagus.
Choice D Reason:
Blood-tinged sputum is not a common symptom of GERD. While severe cases of GERD can lead to complications such as esophagitis or esophageal ulcers, which might cause bleeding, this is not typical in most GERD cases. Blood-tinged sputum would warrant further investigation to rule out other conditions such as infections or malignancies.
Choice E Reason:
Flatulence, or excessive gas, can be associated with GERD. The digestive process can be affected by the reflux of stomach acid, leading to increased gas production and bloating. While not as prominent as dyspepsia or regurgitation, flatulence can still be a symptom experienced by patients with GERD.
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