A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?
Check the client's gag reflex.
Inform the client they might experience a low-grade fever.
Provide the client with sips of water.
Instruct the client to report bleeding.
The Correct Answer is A
The nurse should assess the client's gag reflex before allowing oral intake to prevent aspiration. The client's throat may be numb after a bronchoscopy, which is a procedure that uses a thin tube with a camera and light to examine the lungs and airways . The other actions are important but not the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should plan to confirm the correct position of the line by obtaining a blood sample, as this is one of the methods to verify placement and patency of a central venous catheter. The nurse should also instruct the client to perform a Valsalva maneuver (bearing down) as the catheter is inserted, place the head of the client's bed higher than 30 degrees, and cleanse the site with an antiseptic solution such as chlorhexidine.
Correct Answer is D
Explanation
The nurse should instruct the client to trim toenails straight across to prevent ingrown toenails and infection. The nurse should also advise the client to inspect the feet daily for any signs of injury or ulceration, to avoid applying lotion between the toes as this can cause maceration and fungal growth, and to avoid soaking the feet as this can dry out the skin and increase the risk of injury.
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