A nurse is assisting with the care of a client who had a bronchoscopy 12 hr ago. Which of the following findings should the nurse report to the provider?

The client has inspiratory stridor

The client reports a sore throat.

The client's sputum has streaks of blood.

The client's temperature is 38.6" C/101.4 F

Answer and Explanation

The Correct Answer is A

A. The client has an inspiratory stridor. Inspiratory stridor indicates airway obstruction or laryngeal edema, a potentially life-threatening complication following a bronchoscopy that requires immediate intervention.
B. The client reports a sore throat: A sore throat is common after bronchoscopy due to irritation from the scope. This does not require reporting.
C. The client’s sputum has streaks of blood: Small amounts of blood in sputum are expected due to minor mucosal trauma.
D. The client’s temperature is 38.6°C (101.4°F): Mild fever can occur post-procedure due to inflammation but should only be reported if it persists or other infection signs develop.

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Correct Answer is B

Explanation

A. "Prefers not to look at the stoma site.": Avoidance suggests denial or difficulty accepting the body change.
B. "Participates in performing ostomy care." Active participation in care indicates the client is adjusting to their new body image and accepting their altered appearance.
C. "Denies feelings of sadness about the ostomy.": Denial of emotions does not necessarily mean acceptance. Acknowledging and expressing feelings is important for adjustment.
D. "Accepts that sexual activity will decrease.": This statement reflects resignation rather than acceptance. Many clients with a colostomy maintain an active sexual life.

A. "Plan to hire a home care aid to perform all of your ADLs. B. "You will not become fatigued when you use assistive devices. C. "Install grab bars in your shower to assist with your balance. D. "Place a towel in the shower to prevent slipping.

Correct Answer is C

Explanation

A. "Plan to hire a home care aide to perform all of your ADLs.": Encouraging independence is vital for rehabilitation. Assistance should be provided only as needed.
B. "You will not become fatigued when you use assistive devices.": Using assistive devices can still be tiring; clients should be informed to take frequent breaks.
C. "Install grab bars in your shower to assist with your balance." Grab bars are essential for safety, as clients who have a CVA may have weakness or poor balance, increasing the risk of falls.
D. "Place a towel in the shower to prevent slipping.": Towels in the shower are not safe and can increase the risk of slipping. A non slip mat is a better alternative.

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A nurse is assisting with the care of a client who had a bronchoscopy 12 hr ago. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

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