A nurse is monitoring an older adult client immediately following a bronchoscopy.
The nurse's priority is to monitor the client for which of the following?
Observing for confusion.
Auscultating breath sounds.
Measuring blood pressure.
Confirming the gag reflex.
The Correct Answer is D
Choice A rationale
While observing for confusion is important, especially in older adults who may experience post-operative delirium or hypoxia, it is not the absolute priority immediately after a bronchoscopy. Confusion can be a sign of many issues, but airway protection must be established first. Assessing the neurological status is part of a comprehensive post-procedural assessment, but it follows the immediate physiological safety checks required to prevent aspiration and ensure the patient is stabilized.
Choice B rationale
Auscultating breath sounds is a necessary part of the post-bronchoscopy assessment to check for complications like a pneumothorax or diminished air entry. However, the immediate risk following the administration of local anesthesia to the throat is the loss of protective airway reflexes. While breath sounds provide information about lung expansion, the ability to protect the airway from gastric contents or saliva takes precedence in the very first moments of the recovery phase to prevent aspiration.
Choice C rationale
Measuring blood pressure is a standard part of monitoring vital signs to ensure hemodynamic stability after any procedure involving sedation. While hypotension or hypertension can occur, it is generally considered a lower priority than airway management. Normal blood pressure is typically 120 over 80 mmHg. Monitoring vitals helps detect internal bleeding or reactions to anesthesia, but the immediate physical obstruction or aspiration risk is the most critical factor to address first.
Choice D rationale
The primary concern after a bronchoscopy is the return of the gag reflex. During the procedure, the pharynx is typically numbed with a local anesthetic to prevent coughing and gagging. Until this reflex returns, the patient is at a high risk for aspiration. The nurse must keep the patient NPO (nothing by mouth) and confirm the gag reflex is intact before allowing any oral intake. Ensuring airway protection is always the highest priority in the nursing process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Directly Observed Therapy is a specific strategy used during the treatment phase of tuberculosis and is not a diagnostic tool. Diagnosis of tuberculosis relies on sputum cultures, acid-fast bacilli smears, chest X-rays, and molecular tests like GeneXpert. Because DOT focuses on the administration of medication after a diagnosis has already been established, it does not improve the accuracy of the initial identification of the Mycobacterium tuberculosis pathogen in the clinical setting.
Choice B rationale
While public health programs often provide tuberculosis medications for free or at a subsidized cost to improve accessibility, the primary clinical objective of Directly Observed Therapy is not financial. The infrastructure required to have a trained healthcare worker or designated individual witness every dose actually increases the administrative and labor costs of the program. Therefore, reducing medication costs is a separate policy goal and not the functional purpose of the DOT protocol itself.
Choice C rationale
The primary goal of DOT is to ensure strict adherence to the complex and lengthy multi-drug regimen required to cure tuberculosis. Non-compliance is the leading cause of treatment failure, relapse, and the development of multidrug-resistant tuberculosis (MDR-TB). By having a healthcare provider watch the patient swallow their medication, the program guarantees that the full course is completed. This intervention protects both the individual patient and public health by reducing the transmission of the bacteria.
Choice D rationale
While the interaction between a patient and their DOT provider can offer some level of social interaction and emotional support, this is a secondary benefit rather than the primary medical purpose. The protocol is strictly designed as a public health intervention to manage medication compliance. Social support networks for TB patients are usually facilitated through counseling services, support groups, or community outreach programs rather than the structured, observation-based medication delivery system defined by DOT.
Correct Answer is C
Explanation
Choice A rationale
Positioning a patient flat on their back, or supine, is contraindicated for individuals with chronic obstructive pulmonary disease who are practicing breathing techniques. This position causes the abdominal organs to push upward against the diaphragm, restricting its downward movement and increasing the work of breathing. Patients should ideally be in an upright or semi-Fowler position to allow for maximal diaphragmatic excursion and better lung expansion. Normal diaphragmatic movement is essential for reducing the respiratory rate and improving ventilation efficiency in diseased lungs.
Choice B rationale
Forceful coughing during the exhalation phase of pursed-lipped breathing is counterproductive and physiologically damaging for patients with chronic obstructive pulmonary disease. These patients often have weakened alveolar walls and narrowed airways. Forceful coughing increases intra-thoracic pressure, which can cause the small, floppy airways to collapse prematurely, trapping more air in the distal lungs. The goal of this breathing technique is to maintain a steady, controlled outward flow of air to keep the airways open, rather than creating turbulent or obstructive pressure.
Choice C rationale
Inhaling through the nose and exhaling through the mouth is the core physiological mechanism of pursed-lipped breathing. Inhaling through the nasal passages allows the air to be filtered, warmed, and humidified. Exhaling through pursed lips creates a small amount of positive end-expiratory pressure within the airways. This back-pressure keeps the bronchioles open longer during the expiratory phase, which facilitates the removal of trapped carbon dioxide and allows for more effective oxygen exchange in the alveoli, ultimately reducing the patient's shortness of breath.
Choice D rationale
In pursed-lipped breathing, the physiological goal is to ensure that the expiratory phase is significantly longer than the inspiratory phase. Typically, the nurse instructs the patient to exhale for at least twice as long as they inhale. Prolonging expiration helps to empty the lungs of stale, carbon-dioxide-rich air that is often trapped in the hyperinflated lungs of those with chronic obstructive pulmonary disease. If inspiration is longer than expiration, the patient will continue to experience air trapping, which increases the residual volume and worsens dyspnea.
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