A nurse is caring for a patient who has just returned to the unit following a bronchoscopy and requests coffee.
The nurse assesses that it is safe for the patient to resume oral liquids when which of the following behaviors is demonstrated?
The patient can drink water through a straw without choking.
The patient has intact cough and swallowing reflexes.
The patient has clear breath sounds upon auscultation.
The patient reports that they are not experiencing a sore throat.
The Correct Answer is B
Choice A rationale
While being able to drink water through a straw without choking is a positive sign, it is not the primary indicator that a patient can safely resume oral liquids after a bronchoscopy. The primary indicator is the return of the patient’s cough and swallowing reflexes.
Choice B rationale
The patient has intact cough and swallowing reflexes is the primary indicator that a patient can safely resume oral liquids after a bronchoscopy. These reflexes are essential for preventing aspiration, which can lead to pneumonia.
Choice C rationale
While clear breath sounds upon auscultation are a positive sign, they are not the primary indicator that a patient can safely resume oral liquids after a bronchoscopy. The primary indicator is the return of the patient’s cough and swallowing reflexes.
Choice D rationale
The absence of a sore throat is not the primary indicator that a patient can safely resume oral liquids after a bronchoscopy. The primary indicator is the return of the patient’s cough and swallowing reflexes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While the application of anti-embolism stockings can be beneficial in preventing deep vein thrombosis in postoperative patients, it is not the most prioritized nursing intervention in the immediate postoperative period for a patient who has undergone a left pneumonectomy. The immediate postoperative period after a pneumonectomy is critical for monitoring and managing potential complications such as respiratory distress, hemorrhage, and bronchopleural fistula.
Choice B rationale
The use of the incentive spirometer is an important nursing intervention for postoperative patients to promote lung expansion and prevent atelectasis. However, in the immediate postoperative period following a pneumonectomy, the priority is to monitor for complications and ensure the stability of the patient.
Choice C rationale
Assessment of the chest tube and pleur-evac is the most prioritized nursing intervention in the immediate postoperative period for a patient who has undergone a left pneumonectomy. After a pneumonectomy, a chest tube is placed to drain air, blood, and fluid from the pleural space to allow the remaining lung to re-expand. It is crucial to monitor the chest tube system for proper functioning and to assess for complications such as excessive bleeding, infection, or pneumothorax.
Choice D rationale
Repositioning the patient in bed is a standard nursing intervention in postoperative care to enhance comfort, promote lung expansion, and prevent complications such as pressure ulcers and deep vein thrombosis. However, it is not the most prioritized intervention in the immediate postoperative period following a pneumonectomy, where monitoring for respiratory complications and ensuring the stability of the patient are paramount.
Correct Answer is C
Explanation
Choice A rationale
Written competency exams can assess theoretical knowledge and understanding of procedures, but they may not accurately reflect practical skills or performance under real-life conditions.
Choice B rationale
Insence training, while potentially beneficial for enhancing certain skills, may not be the most effective method for improving confidence and performance in response to a “code”. It lacks the realism and immediacy of a code situation.
Choice C rationale
Simulation-based mock codes provide a safe environment where staff can practice their skills, learn from their mistakes, and improve their performance without risk to patients. They can enhance confidence, competence, and performance in real code situations.
Choice D rationale
Peer-to-peer feedback sessions can provide valuable insights and foster a culture of continuous learning and improvement. However, they may not offer the same level of structured, targeted skill development and performance improvement as simulation-based mock codes.
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