A nurse is caring for a client who just had a flexible bronchoscopy.
Which of the following nursing actions is appropriate?

Irrigate the client's throat every 4 hours.

Withhold food and liquids until the client's gag reflex returns.

Suction the client's oropharynx frequently.

Have the client refrain from talking for 24 hours.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Irrigating the client's throat can introduce fluid into the airway before the gag reflex has returned, significantly increasing the risk of aspiration. This practice is contraindicated in the immediate post-bronchoscopy period due to residual topical anesthetic effects.

Choice B rationale

Topical anesthetics are used during bronchoscopy to suppress the gag reflex and discomfort. Until this reflex, which protects the airway from aspiration, has fully returned, withholding food and liquids is crucial to prevent aspiration of foreign material into the lungs.

Choice C rationale

While some oral secretions may be present, frequent oropharyngeal suctioning can cause mucosal trauma or stimulate gagging before the gag reflex is fully restored, potentially inducing vomiting and increasing aspiration risk. It should be performed only as needed, judiciously.

Choice D rationale

Refraining from talking for 24 hours is unnecessary after a flexible bronchoscopy. While some clients may experience mild hoarseness or sore throat, vocal rest is not a standard or required post-procedure intervention and does not pose a significant risk if the gag reflex is intact. .

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Correct Answer is C

Explanation

Choice A rationale

Disseminated intravascular coagulation (DIC) is an acquired disorder of coagulation, not a genetic one. It is typically triggered by severe underlying conditions like sepsis or trauma, leading to systemic activation of coagulation, rather than an inherited predisposition or a direct vitamin K deficiency.

Choice B rationale

DIC is characterized by widespread microthrombi formation, which consumes platelets and clotting factors. This consumption leads to a *decreased* platelet count, often below the normal range of 150-400 × 10^9/L, in contrast to an elevated count, which would indicate a different coagulopathy.

Choice C rationale

DIC is caused by abnormal, widespread activation of the coagulation cascade, leading to excessive fibrin and thrombin generation. This consumes clotting factors, including fibrinogen (normal range 2.0-4.0 g/L), and platelets, resulting in simultaneous widespread clotting and bleeding from factor depletion.

Choice D rationale

DIC is a complex, acute, and often life-threatening condition where the underlying cause must be treated. While heparin may be used cautiously in some hypercoagulable phases to inhibit thrombin formation, it is not a universally applied, lifelong treatment and can exacerbate bleeding in many DIC patients.

A. Excessive thrombosis and bleeding. B. Progressive increase in platelet production. C. Increased clotting factors. D. Immediate sodium and fluid retention.

Correct Answer is A

Explanation

Choice A rationale

Disseminated intravascular coagulation (DIC) is a complex, life-threatening disorder characterized by widespread activation of the coagulation cascade, leading to the formation of microthrombi throughout the microvasculature. This extensive clotting consumes platelets and clotting factors, ultimately resulting in paradoxical bleeding due to the depletion of hemostatic components and enhanced fibrinolysis. Thus, both excessive thrombosis and bleeding are hallmark findings.

Choice B rationale

In DIC, there is a progressive *decrease* in platelet production and consumption, not an increase. The widespread clotting consumes available platelets, leading to thrombocytopenia, which is a key diagnostic feature and contributes significantly to the bleeding manifestations. Bone marrow function is typically not stimulated to overproduce platelets in DIC.

Choice C rationale

DIC is characterized by the *consumption* of clotting factors, not an increase. The uncontrolled activation of coagulation pathways rapidly depletes fibrinogen, prothrombin, factors V, VIII, and XIII. This depletion leads to a coagulopathy that manifests as significant bleeding, despite the initial hypercoagulable state.

Choice D rationale

While severe physiological stress can impact fluid balance, immediate sodium and fluid retention are not primary or specific findings of DIC. DIC is primarily a disorder of hemostasis and coagulation, leading to microthrombosis and bleeding. Fluid balance abnormalities might occur secondary to organ dysfunction or critical illness associated with DIC, but not as direct manifestations.

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A nurse is caring for a client who just had a flexible bronchoscopy.
Which of the following nursing actions is appropriate?