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
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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Related Questions
Correct Answer is D
Explanation
A. "You will need to fast for 2 hours before the procedure." Bone marrow aspiration typically does not require fasting. If the procedure involves sedation, the client may be instructed to fast for a certain period, but fasting is not a standard requirement for bone marrow aspiration.
B. "You will have the bone marrow taken from your femur." While the femur (thigh bone) can be a site for bone marrow aspiration, the most common site is the posterior iliac crest (the back of the pelvis). The nurse should clarify the exact site with the healthcare provider.
C. "You will not receive a local anesthetic agent for this procedure." Bone marrow aspiration is typically performed under local anesthesia to minimize discomfort at the site. The client will feel pressure during the procedure but should not experience pain due to the anesthesia.
D. "I will hold pressure on the site after the procedure." After a bone marrow aspiration, the nurse will apply pressure to the site to control any bleeding and help prevent hematoma formation. This is an important part of post-procedure care.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Open the splint: Reduces pressure and alleviates compartment syndrome.
Place the client on NPO status: Anticipated in preparation for possible surgery (e.g., fasciotomy).
Place the leg in a dependent position: Contraindicated as it can worsen swelling and increase pressure.
Obtain a urinalysis: Necessary to monitor for myoglobinuria, a potential complication of muscle damage in compartment syndrome.
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