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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale
CBC results are not directly related to the initiation of alendronate therapy.
Choice B rationale
Family history of colon cancer is not relevant to alendronate therapy.
Choice C rationale
Thyroid function is not directly related to alendronate therapy.
Choice D rationale
Pregnancy status should be assessed as alendronate is contraindicated during pregnancy.

A. Vomiting. B. Dilated pupils. C. Bruising. D. Peripheral edema.

Correct Answer is A

Explanation

Choice A rationale
Vomiting is a common sign of digoxin toxicity. Other symptoms include nausea, confusion, and visual disturbances.
Choice B rationale
Dilated pupils are not a typical sign of digoxin toxicity. Symptoms are more related to gastrointestinal and cardiac effects.
Choice C rationale
Bruising is not directly associated with digoxin toxicity. It may indicate other issues such as coagulopathy.
Choice D rationale
Peripheral edema is not a specific sign of digoxin toxicity. It is more commonly associated with heart failure.

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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.)

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Naxlex Comprehensive Predictor Exams

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