A nurse is collecting data from a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?

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

This is the correct action. After a bronchoscopy, the client's throat may be numb or irritated from the procedure, which can temporarily impair the gag reflex. Withholding food and liquids until the gag reflex returns reduces the risk of aspiration, where food or liquid enters the airway instead of the stomach. Aspiration can lead to pneumonia and other serious complications. Therefore, it's essential to assess the client's gag reflex before allowing them to eat or drink.

B. Irrigate the client's throat every 4 hours.

This action is not necessary and may even be harmful. Irrigating the client's throat every 4 hours could further irritate the throat and increase discomfort for the client. Unless specifically ordered by the healthcare provider for a specific reason, such as to remove secretions or debris, routine irrigation of the throat is not recommended after a bronchoscopy.

C. Have the client refrain from talking for 24 hours.

There is typically no need for the client to refrain from talking for 24 hours after a bronchoscopy. While the client may experience some throat discomfort and hoarseness, restricting talking for such an extended period is unnecessary and may cause undue stress or anxiety for the client. Unless specifically instructed by the healthcare provider for a valid reason, such as to allow vocal cord healing, there is no need to restrict talking for such a long duration.

D. Suction the client's oropharynx frequently.

Frequent suctioning of the client's oropharynx is not indicated unless there is a specific medical reason to do so. Excessive suctioning can cause trauma to the mucous membranes, increase the risk of infection, and exacerbate throat irritation. The decision to suction should be based on clinical assessment, such as evidence of secretions or if the client is having difficulty clearing their airway, rather than being performed routinely.

A. Encourage fluid intake of 2.5 L per day.

This is an appropriate intervention for a client with pneumonia. Increasing fluid intake helps to thin respiratory secretions, making them easier to cough up and clear from the airways. Adequate hydration also supports overall health and immune function. However, the nurse should consider the client's individual fluid tolerance and any comorbid conditions such as heart failure that may necessitate fluid restriction.

B. Assist the client to cough and deep breathe every 4 hr.

This intervention is also appropriate for a client with pneumonia. Coughing and deep breathing exercises help to mobilize and clear respiratory secretions, preventing complications such as atelectasis and pneumonia. However, the frequency of coughing and deep breathing may need to be tailored to the client's tolerance and respiratory status.

C. Encourage independence in completing ADLs.

While promoting independence in activities of daily living (ADLs) is generally beneficial for older adult clients, in the context of pneumonia, the priority is to ensure adequate rest and conserve energy for recovery. Depending on the severity of the illness, the client may experience fatigue and dyspnea, making it challenging to perform ADLs independently. The nurse should assess the client's functional status and provide assistance as needed while promoting independence to the extent possible.

D. Use an N-95 respirator when providing client care.

This intervention is not directly relevant to the care plan for a client with pneumonia. N-95 respirators are primarily used for respiratory protection against airborne infectious agents such as tuberculosis or certain viral infections like COVID-19. While standard precautions should be followed when caring for a client with pneumonia to prevent the spread of infection, including hand hygiene and appropriate use of personal protective equipment (PPE), an N-95 respirator is not typically indicated unless the client has a specific respiratory pathogen requiring airborne precautions.