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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While monitoring clients is important, placing a client with active tuberculosis in a room within view of the nurses' station does not address the fundamental need for infection control. Tuberculosis is an airborne disease requiring specific environmental controls to prevent transmission, which this choice does not provide.
Choice B rationale
A room with air exhaust directly to the outdoor environment, often called a negative pressure room or airborne infection isolation room (AIIR), is essential for clients with active tuberculosis. This design prevents airborne mycobacteria from circulating within the healthcare facility, directing them outside to reduce the risk of transmission to others.
Choice C rationale
Placing a client with active tuberculosis in the ICU is generally unnecessary unless their clinical condition warrants critical care, such as respiratory failure. The primary concern for tuberculosis is airborne isolation, which can be achieved on a regular medical-surgical unit with appropriate room design and ventilation, not necessarily an ICU level of care.
Choice D rationale
Cohabiting a client with active tuberculosis with another nonsurgical client is highly inappropriate and unsafe. Tuberculosis is transmitted via airborne particles, and co-rooming would expose the other client to a significant risk of infection. Dedicated isolation is paramount for preventing nosocomial spread.
Correct Answer is A
Explanation
Choice A rationale
An absolute neutrophil count (ANC) less than 1,000/mm³ indicates neutropenia, which significantly increases the risk of infection. Limiting visitors to healthy adults minimizes exposure to pathogens that could be carried by individuals who are ill or immunocompromised, thereby reducing the risk of opportunistic infections.
Choice B rationale
Taking a rectal temperature is contraindicated in neutropenic clients due to the risk of introducing bacteria from the rectum into the bloodstream, which could lead to bacteremia or sepsis. Oral or axillary temperatures are preferred methods for temperature assessment in immunocompromised individuals to prevent mucosal trauma.
Choice C rationale
Increasing raw produce in the client's diet is contraindicated in neutropenic clients. Uncooked fruits and vegetables can harbor bacteria and fungi that, while usually harmless to individuals with intact immune systems, can cause severe infections in immunocompromised patients due to compromised gut mucosal barriers.
Choice D rationale
Instructing the client to floss his teeth daily is contraindicated in severe neutropenia. Flossing can cause micro-abrasions and bleeding of the gingiva, creating entry points for oral bacteria into the bloodstream, which can lead to systemic infections in a client with a severely compromised immune system.
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