A nurse is collecting data from a client who had a bronchoscopy. Which of the following findings should the nurse report to the provider?
Sore throat
Blood pressure 110/78 mm Hg
Facial edema
Presence of gag reflex
The Correct Answer is C
Choice A: This is incorrect because sore throat is not a finding that the nurse should report to the provider. Sore throat is a common and expected complication of bronchoscopy due to irritation from the endoscope. The nurse should provide oral care and offer ice chips or lozenges to soothe the throat.
Choice B: This is incorrect because blood pressure 110/78 mm Hg is not a finding that the nurse should report to the provider. Blood pressure 110/78 mm Hg is within the normal range and does not indicate any adverse effects from bronchoscopy. The nurse should monitor the vital signs and oxygen saturation of the client.
Choice C: This is correct because facial edema is a finding that the nurse should report to the provider. Facial edema can indicate an allergic reaction, airway obstruction, or mediastinal emphysema, which are serious and potentially life-threatening complications of bronchoscopy. The nurse should assess the airway, breathing, and circulation of the client and administer oxygen and medications as prescribed.
Choice D: This is incorrect because presence of gag reflex is not a finding that the nurse should report to the provider. Presence of gag reflex is an expected outcome of bronchoscopy, indicating that the anesthesia has worn off and the client can resume oral intake. The nurse should check the gag reflex before offering any food or fluids to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: This is correct. Phototherapy is a treatment option for psoriasis that involves exposing the skin to ultraviolet light, which can reduce inflammation and slow down the growth of skin cells.
Choice B: This is incorrect. Oil-based ointment is not recommended for psoriasis, as it can clog the pores and worsen the condition.
Choice C: This is incorrect. Dermabrasion is a cosmetic procedure that involves removing the outer layer of skin with a rotating device, which can cause bleeding, infection, and scarring.
Choice D: This is incorrect. Benzoyl peroxide is an acne medication that can dry out and irritate the skin, which can aggravate psoriasis.
Correct Answer is B
Explanation
Choice A reason: Keeping both arms below the level of the client's heart can increase venous pressure and fluid accumulation in the affected arm, which can lead to lymphedema.
Choice B reason: After a mastectomy, it’s important to avoid procedures like blood draws, injections, or blood pressure measurements on the side where the surgery was performed to prevent lymphedema. Therefore, using the client’s left arm for blood samples is a preventive measure.
Choice C reason: Obtaining blood pressure readings using the client's right arm is an incorrect action that can increase lymphatic fluid accumulation and impair circulation in the affected arm.
Choice D reason: Limiting range-of-motion exercises with the affected arm is an incorrect action that can decrease lymphatic drainage and increase swelling in the affected arm. The nurse should encourage the client to perform gentle exercises, such as squeezing a soft ball or raising and lowering the arm, to promote lymphatic flow and prevent stiffness.
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