A client who had a bronchoscopy 2 hours ago asks for a drink of water. What action would the nurse take initially to assure client safety?

Assess the client’s gag reflex before giving any food or water.

Provide the client with ice chips instead of a drink of water.

Contact the primary healthcare provider and get the appropriate orders.

Let the client have a small sip to evaluate the ability to swallow.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Assessing the client’s gag reflex before giving any food or water is crucial after a bronchoscopy. The procedure involves the use of local anesthesia to numb the throat, which can impair the gag reflex and increase the risk of aspiration. Ensuring that the gag reflex has returned before allowing the client to eat or drink helps prevent choking and aspiration, which are serious complications.

Choice B Reason:

Providing the client with ice chips instead of a drink of water is not the best initial action. While ice chips may seem like a safer option, they still pose a risk of aspiration if the gag reflex has not fully returned. The priority is to first assess the gag reflex to ensure the client can safely swallow.

Choice C Reason:

Contacting the primary healthcare provider and getting the appropriate orders is not necessary as the first action. The nurse can independently assess the gag reflex, which is a standard nursing practice after procedures involving throat anesthesia. If there are concerns after the assessment, then contacting the healthcare provider would be appropriate.

Choice D Reason:

Letting the client have a small sip to evaluate the ability to swallow is not safe without first assessing the gag reflex. This approach could lead to aspiration if the gag reflex has not returned. The initial step should always be to assess the gag reflex to ensure the client can safely swallow liquids.

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Free Nursing Study Resources

Correct Answer is ["B","C","E","F"]

Explanation

Choice A Reason:

Weight gain is not typically associated with tuberculosis (TB). In fact, weight loss is a common symptom of TB due to the chronic nature of the infection and the body’s increased metabolic demands to fight the disease. Patients with TB often experience a loss of appetite and significant weight loss as the disease progresses.

Choice B Reason:

Low-grade fever is a common symptom of TB. The body’s immune response to the infection often results in a persistent low-grade fever, which can be one of the early signs of the disease. This fever is usually accompanied by other systemic symptoms such as night sweats and fatigue.

Choice C Reason:

Dyspnea, or difficulty breathing, can occur in patients with TB, especially if the infection has caused significant lung damage or if there is a large amount of fluid in the pleural space (pleural effusion). Dyspnea is a concerning symptom that indicates the need for further evaluation and treatment.

Choice D Reason:

Contusion, or bruising, is not a symptom associated with TB. TB primarily affects the lungs and can cause systemic symptoms, but it does not typically cause bruising. Contusions are more commonly associated with trauma or conditions that affect blood clotting.

Choice E Reason:

Lethargy, or a general sense of fatigue and weakness, is a common symptom of TB. The chronic nature of the infection and the body’s ongoing immune response can lead to significant fatigue. Patients with TB often feel tired and may have difficulty performing daily activities.

Choice F Reason:

Night sweats are a hallmark symptom of TB. Patients often experience drenching night sweats that can be quite severe. This symptom, along with fever and weight loss, is part of the classic triad of TB symptoms and is an important indicator for healthcare providers to consider TB in the differential diagnosis.

A. Provide a quiet, low-stimulus environment B. Keep the client NPO C. Administer aspirin as prescribed for any sign of hyperthermia D. Observe the client carefully for signs of hypocalcemia

Correct Answer is A

Explanation

Provide a quiet, low-stimulus environment

Choice A Reason:

Provide a quiet, low-stimulus environment

This is the correct answer. A quiet, low-stimulus environment helps to reduce the metabolic demands on the body and prevent overstimulation, which can trigger a thyroid crisis. Hyperthyroidism increases the body’s metabolic rate, and excessive stimulation can exacerbate symptoms and lead to a crisis. Therefore, creating a calm environment is crucial in managing hyperthyroidism and preventing complications.

Choice B Reason:

Keep the client NPO

Keeping the client NPO (nothing by mouth) is not typically necessary for preventing a thyroid crisis. While it may be required for certain procedures or if the client is experiencing severe symptoms, it is not a standard intervention for hyperthyroidism management. Therefore, this choice is not correct.

Choice C Reason:

Administer aspirin as prescribed for any sign of hyperthermia

Administering aspirin for hyperthermia is not recommended in clients with hyperthyroidism. Aspirin can increase free thyroid hormone levels by displacing thyroid hormones from their binding proteins, potentially worsening hyperthyroidism. Instead, other antipyretics like acetaminophen are preferred. Therefore, this choice is not correct.

Choice D Reason:

Observe the client carefully for signs of hypocalcemia

Observing for signs of hypocalcemia is not directly related to preventing a thyroid crisis. Hypocalcemia is more commonly associated with thyroidectomy or parathyroidectomy rather than hyperthyroidism itself. Therefore, this choice is not correct.

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A client who had a bronchoscopy 2 hours ago asks for a drink of water. What action would the nurse take initially to assure client safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which sign or symptom would the nurse anticipate in a patient diagnosed with tuberculosis? Select all that apply. One, some, or all responses may be correct.

Correct Answer is ["B","C","E","F"]

Explanation

Correct Answer is A

Explanation

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