A nurse is gathering information from a patient who has undergone a bronchoscopy. Which of the following observations should the nurse report to the healthcare provider?

Sore throat

Presence of gag reflex

Blood pressure 110/88 mm Hg

Facial edema

Answer and Explanation

The Correct Answer is D

A. Sore throat: A sore throat is a common side effect following a bronchoscopy due to irritation of the airway. It is typically expected and does not indicate a serious complication.

B. Presence of gag reflex: The return of the gag reflex after a bronchoscopy is a normal finding. It indicates that the protective airway reflexes are intact, which is a positive sign.

C. Blood pressure 110/88 mm Hg: Although the diastolic pressure is a bit high, this blood pressure reading is generally acceptable post-procedure and is not typically concerning in the context of a bronchoscopy.

D. Facial edema: Facial edema is not a normal finding following a bronchoscopy. It may indicate an allergic reaction, adverse response to medications used during the procedure, or a complication such as airway edema. This finding should be reported immediately to the healthcare provider as it could signal a potentially serious condition.

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Correct Answer is A

Explanation

Comparing the current blood pressure reading to the preoperative value is the first step the nurse should take. This will help determine if the patient’s blood pressure has significantly dropped, which could indicate hypovolemia or shock.

Choice B rationale

Covering the patient with a warm blanket may be helpful if the patient is feeling cold or showing signs of hypothermia, but it would not address the underlying cause of the low blood pressure.

Choice C rationale

Increasing the IV flow rate might be necessary if the patient is hypovolemic, but this decision should be based on additional assessment data and physician orders.

Choice D rationale

Reassuring the patient is important, but it should not be the first action. The nurse needs to assess and address the cause of the low blood pressure.

A. The patient enjoys a glass of red wine every evening. B. The patient walks 3.2 km (2 mi) daily. C. The patient is lactose intolerant. D. The patient is a gardener.

Correct Answer is C

Explanation

Choice A rationale

Enjoying a glass of red wine every evening is not directly linked to an increased risk of osteoporosis. While excessive alcohol consumption can contribute to bone loss, moderate consumption (up to one drink per day for women and up to two drinks per day for men) does not appear to significantly affect bone mineral density.

Choice B rationale

Regular physical activity, such as walking, is actually beneficial for bone health. Weight-bearing exercises, including walking, can help increase bone density and reduce the risk of osteoporosis.

Choice C rationale

Lactose intolerance can increase the risk of osteoporosis. Individuals with lactose intolerance often avoid dairy products, which are a major source of dietary calcium. Calcium is essential for bone health, and inadequate calcium intake can lead to decreased bone density and an increased risk of osteoporosis.

Choice D rationale

Gardening is a form of physical activity, and like walking, it can help increase bone density and reduce the risk of osteoporosis. There is no evidence to suggest that gardening increases the risk of osteoporosis.

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A nurse is gathering information from a patient who has undergone a bronchoscopy. Which of the following observations should the nurse report to the healthcare provider?

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