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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Give your son plenty of alone time with his sister." While supervised interaction is important, unsupervised alone time is not recommended for preschoolers and newborns due to safety concerns. Young children may not fully understand appropriate handling or boundaries.
B. "Plan for your son to meet his sister for the first time at home." Introducing the baby at the hospital is generally encouraged, as it allows for early bonding in a supportive environment. Waiting until home may delay adjustment and could create feelings of exclusion.
C. "Give your son a little gift from his new sister." This strategy helps reduce feelings of jealousy and promotes positive associations with the new baby. It can make the older sibling feel acknowledged and included in the family transition.
D. "Hold your daughter when your son first meets her." Holding the baby during the first introduction may make the older child feel displaced. Allowing the parent to focus attention on the older sibling during the initial meeting can foster reassurance and connection.
Correct Answer is A
Explanation
A. "I will avoid crushing this medication." Metformin extended-release tablets should be swallowed whole to maintain the time-release mechanism. Crushing or chewing the tablet can lead to rapid drug release, increasing the risk of adverse effects like gastrointestinal distress or lactic acidosis.
B. "I will take the medication in the morning." While many clients take metformin in the morning, the key instruction is to take it with food to reduce gastrointestinal side effects. Timing can vary depending on the dosing schedule prescribed by the provider.
C. "I will take the medication on an empty stomach." Taking metformin on an empty stomach increases the likelihood of nausea, abdominal pain, and diarrhea. It should always be taken with meals to enhance tolerance and absorption.
D. "I will expect to gain weight." Metformin is weight-neutral or may even contribute to mild weight loss. It is often preferred for overweight clients with type 2 diabetes due to its favorable metabolic profile.
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