A nurse is caring for a client 15 min following a bronchoscopy with moderate sedation. Which of the following actions should the nurse take first?
Offer the client oral fluids.
Check the client's IV site.
Obtain the client's oxygen saturation level.
Determine the client's level of consciousness.
The Correct Answer is C
A. Offer the client oral fluids: Fluids should not be offered until the client’s gag reflex has returned to prevent aspiration. Offering fluids too soon after a bronchoscopy places the client at significant risk for aspiration pneumonia due to airway suppression from sedation.
B. Check the client’s IV site: While important, this is not the priority in the immediate post-procedure period. IV site assessment ensures patency and absence of complications, but it does not address the client’s airway or oxygenation status, which are more urgent concerns.
C. Obtain the client’s oxygen saturation level: Airway and oxygenation take top priority following sedation and bronchoscopy, especially since the procedure can cause respiratory depression or airway compromise. Measuring oxygen saturation is essential to detect early hypoxia and ensure respiratory stability.
D. Determine the client’s level of consciousness: While evaluating consciousness is important after moderate sedation, it comes after assessing oxygenation. A decreased oxygen level could lead to altered mental status, so it’s more critical to assess oxygenation first.
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Related Questions
Correct Answer is C
Explanation
A. Set the hot water heater to 52° C (125° F):This temperature is too high and increases the risk of scalding. The recommended setting for home water heaters is below 49° C (120° F) to prevent burns in infants and young children.
B. Place the playpen near a heat vent during cold weather:Placing the playpen near a heat vent can expose the infant to burns or overheating. It's important to maintain a safe distance from direct heat sources.
C. Position the crib away from the cords of blinds and drapes:This helps prevent strangulation hazards. Crib placement away from window cords and drapes is essential for newborn safety.
D. After feeding, place the newborn on his stomach:Placing a newborn on the stomach increases the risk of sudden infant death syndrome (SIDS). The correct position is on the back for sleep.
Correct Answer is ["10"]
Explanation
Calculation:
- Determine the concentration of heparin in the solution.
Total units of heparin = 25,000 units
Total volume of solution = 250 mL
Concentration = 25,000 units / 250 mL
= 100 units/mL.
- Calculate the infusion rate in milliliters per hour (mL/hr).
Desired infusion rate = 1,000 units/hr
Infusion rate (mL/hr) = Desired infusion rate (units/hr) / Concentration (units/mL)
= 1,000 units/hr / 100 units/mL
= 10 mL/hr.
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