A nurse is caring for a client following a bronchoscopy with moderate sedation. Which of the following actions should the nurse take? (Select all that apply.)
Assess the client’s gag reflex before offering oral intake.
Listen to the client’s breath sounds.
Monitor the client’s oxygen saturation.
Monitor the client for manifestations of bleeding.
Assess the client’s puncture site.
Observe the client for manifestations of a pneumothorax.
Correct Answer : A,B,C,D,F
Choice A rationale
Assessing the client’s gag reflex before offering oral intake is essential to prevent aspiration. The gag reflex may be diminished after moderate sedation and the use of local anesthetics during bronchoscopy.
Choice B rationale
Listening to the client’s breath sounds is important to detect any abnormalities, such as wheezing, crackles, or decreased breath sounds, which could indicate complications like bronchospasm or pneumothorax.
Choice C rationale
Monitoring the client’s oxygen saturation is crucial to ensure adequate oxygenation and detect any signs of respiratory distress or hypoxemia following the procedure.
Choice D rationale
Monitoring the client for manifestations of bleeding is necessary because bronchoscopy can cause trauma to the airways, leading to bleeding. Signs of bleeding may include hemoptysis or a drop in hemoglobin levels.
Choice E rationale
Assessing the client’s puncture site is not applicable in this context, as bronchoscopy does not involve a puncture site. This option is incorrect.
Choice F rationale
Observing the client for manifestations of a pneumothorax is important because bronchoscopy can occasionally cause a pneumothorax, especially if a biopsy is performed. Signs of pneumothorax include sudden chest pain, dyspnea, and decreased breath sounds on the affected side.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Choice A rationale
Glucose levels are not typically monitored for patients receiving gentamicin.
Choice B rationale
Prothrombin time is not typically monitored for patients receiving gentamicin.
Choice C rationale
Serum creatinine should be monitored because gentamicin can cause nephrotoxicity, and elevated serum creatinine levels can indicate kidney damage.
Choice D rationale
Cardiac enzymes are not typically monitored for patients receiving gentamicin.
Choice E rationale
WBC count should be monitored because gentamicin can cause leukopenia or other changes in white blood cell counts.
Correct Answer is D
Explanation
Choice A rationale
Limiting caffeine is not the first action the nurse should take. While caffeine can exacerbate symptoms of BPH, it is not the priority action when starting doxazosin IR3.
Choice B rationale
Reporting headaches is important, but it is not the first action the nurse should take. Headaches can be a side effect of doxazosin, but monitoring the patient’s initial response to the medication is more critical.
Choice C rationale
Measuring the client’s intake and output is important for monitoring urinary symptoms, but it is not the first action the nurse should take when starting doxazosin IR3.
Choice D rationale
Administering the medication at bedtime is the correct first action. Doxazosin can cause dizziness and hypotension, especially after the first dose, so taking it at bedtime can help minimize these effects.
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