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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. HCO3 (bicarbonate) levels above 26 mEq/L indicate alkalosis, not acidosis. In metabolic acidosis, the HCO3 levels would be low as the body attempts to neutralize excess acid.
B. In metabolic acidosis, the pH is expected to be below 7.35 because metabolic acidosis indicates an accumulation of acid or loss of bicarbonate, which lowers the blood pH.
C. PaO2 (partial pressure of oxygen) below 70 mm Hg typically indicates hypoxemia, not necessarily metabolic acidosis. The primary concern with metabolic acidosis is the balance of acid-base status, not oxygenation.
D. PaCO2 above 45 mm Hg would suggest respiratory acidosis rather than metabolic acidosis. In metabolic acidosis, the body compensates by hyperventilating to blow off CO2 and raise the pH, resulting in a normal or low PaCO2.
Correct Answer is C
Explanation
A. Moist mucous membranes: This is incorrect. In diabetes insipidus, the body loses large amounts of water due to a deficiency of antidiuretic hormone (ADH) or its effects. As a result, the client often experiences dehydration, leading to dry mucous membranes, not moist ones.
B. Bounding peripheral pulses: This is incorrect. While bounding pulses are often seen in conditions like fluid overload or hypervolemia, diabetes insipidus typically causes dehydration due to excessive urination, which would not lead to bounding pulses. The pulses would more likely be weak or thready due to fluid loss.
C. Urine specific gravity 1.002: This is the correct finding. In diabetes insipidus, the kidneys are unable to concentrate urine, resulting in very dilute urine. A urine specific gravity of 1.002 indicates very diluted urine, which is characteristic of diabetes insipidus.
D. Bradycardia: This is incorrect. Bradycardia (slow heart rate) is not typically associated with diabetes insipidus. In fact, tachycardia (increased heart rate) can occur as a compensatory response to dehydration caused by excessive urination in diabetes insipidus.
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