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

Have the client refrain from talking for 24 hr.

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

Irrigate the client's throat every 4 hr.

Suction the client's oropharynx frequently.

Answer and Explanation

The Correct Answer is B

A. Have the client refrain from talking for 24 hr.: This is unnecessary; the client may talk once the effects of the local anesthetic wear off, typically within an hour or two after the procedure.
B. Withhold food and liquids until the client's gag reflex returns: This is the most important action to prevent aspiration. After a bronchoscopy, the throat is anesthetized, and eating or drinking before the gag reflex returns increases the risk of aspiration.
C. Irrigate the client's throat every 4 hr.: This is not a routine post-procedure intervention and could be uncomfortable for the client.
D. Suction the client's oropharynx frequently: Suctioning should only be performed if the client has difficulty clearing secretions. There is no routine need for frequent suctioning after a bronchoscopy unless clinically indicated.

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Correct Answer is A

Explanation

A. The optimal position for a thoracentesis is sitting upright with the patient leaning forward slightly, with elbows resting on an over-bed table to help expose the pleural space for access. This position allows gravity to pull the lungs downward and facilitates easier access to the pleural cavity.
B. Sitting in bed with knees slightly flexed and feet flexed is not the best position for thoracentesis. This position might limit the ability to properly expose the thoracic cavity for the procedure.
C. Lying flat in the fetal position on the unaffected side would not allow for effective drainage or access to the pleural space and is not ideal for thoracentesis.
D. Lying flat on the unaffected side with knees slightly flexed is not ideal because it does not provide optimal positioning for the procedure. The upright position is preferred for thoracentesis to facilitate easy access to the pleural space.

A. Monitor for postural hypotension B. Assess blood glucose level C. Monitor for an irregular heart rate D. Assess for neck vein distention E. Weigh the client daily

Correct Answer is ["B","D","E"]

Explanation

A. Monitor for postural hypotension: This is unlikely in Cushing’s syndrome, where hypertension (not hypotension) is more common due to excess cortisol and fluid retention.
B. Assess blood glucose level: Hyperglycemia is common in Cushing’s syndrome due to the effects of cortisol on glucose metabolism, so monitoring blood glucose levels is essential.
C. Monitor for an irregular heart rate: While Cushing's syndrome can lead to electrolyte imbalances that may affect heart rhythm, this is not a primary intervention in Cushing's syndrome. Monitoring for hypertension and fluid retention is more critical.
D. Assess for neck vein distention: Elevated cortisol levels can lead to fluid retention and hypertension, contributing to neck vein distention, so this is an important observation.
E. Weigh the client daily: Fluid retention and weight gain are key features of Cushing's syndrome, so daily weight monitoring helps assess fluid status and detect rapid weight gain indicative of worsening symptoms.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assists a patient into which position in preparation for a diagnostic thoracentesis?

Correct Answer is A

Explanation

A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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