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. After administering a carbohydrate source (e.g., 6 oz of orange juice), the nurse should reassess the patient's blood glucose level. If the glucose is still below the target range (typically above 70 mg/dL), the next step is to give an additional 15 grams of carbohydrate to raise the blood sugar. This is a standard approach for mild to moderate hypoglycemia.
B. Giving 25 to 50 ml of 50% glucose IV is typically reserved for patients who are severely hypoglycemic and unable to swallow or are unresponsive. This method is appropriate when the patient cannot take oral glucose, but the client in this scenario is still conscious.
C. Administering 1 mg IM glucagon is used when a patient is unable to ingest glucose orally and is unresponsive or vomiting. It stimulates the liver to release stored glucose, but this is not necessary in a conscious patient who can swallow.
D. Administering a 5% to 10% dextrose infusion is typically used in more severe cases of hypoglycemia, especially when IV access is established, and the patient is unable to take oral glucose. This would not be necessary for a patient who can safely swallow.

A. Place the patient in a lateral recovery position for better drainage of the secretions. B. Activate the rapid-response team. C. Keep monitoring the oxygen saturation and respiratory rate. D. Increase the humidification of the patient's oxygen.

Correct Answer is A

Explanation

A. Placing the patient in a lateral recovery position is the best immediate action. This position helps facilitate drainage of secretions, especially after a laryngectomy, which can reduce the risk of aspiration and airway obstruction. The blood-tinged mucus may be due to recent surgery and should be monitored for changes.
B. The activation of the rapid-response team may be necessary if the patient’s condition worsens or becomes critical, but there is no indication of an acute life-threatening event based on the blood-tinged mucus alone.
C. Monitoring the oxygen saturation and respiratory rate is important, but it is a secondary concern compared to providing a position that promotes drainage and prevents aspiration.
D. Increasing humidification of the oxygen may help keep the airway moist, but the immediate priority should be ensuring proper positioning to allow secretion drainage and prevent aspiration.

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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?

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