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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Correct Answer is D

Explanation

Order a high-fiber diet

Choice A Reason:

Encourage dietary intake

Encouraging dietary intake is generally important for maintaining nutritional status, but it is not specific to the preparation for a barium enema. The preparation for a barium enema typically involves dietary restrictions to ensure the colon is clear for the procedure. Therefore, this choice is not correct.

Choice B Reason:

Encourage plenty of fat

Encouraging plenty of fat is not appropriate for the preparation of a barium enema. High-fat foods can slow down the digestive process and may interfere with the clarity of the images obtained during the procedure. Therefore, this choice is not correct.

Choice C Reason:

Serve dairy products

Serving dairy products is not recommended before a barium enema. Dairy products can cause gas and bloating, which can interfere with the procedure. Additionally, some patients may be lactose intolerant, which can further complicate the preparation. Therefore, this choice is not correct.

Choice D Reason:

Order a high-fiber diet

Ordering a high-fiber diet is the correct choice. A high-fiber diet helps to clear the intestines by promoting bowel movements. This is important for ensuring that the colon is empty and clear for the barium enema, which allows for better imaging and more accurate results.

A. Occasional palpitations B. Weakness C. Shortness of breath

Correct Answer is A

Explanation

Choice A Reason:

Occasional palpitations are a common symptom of supraventricular tachycardia (SVT) with a non-sustained ventricular response. Palpitations are sensations of a rapid, fluttering, or pounding heartbeat, which occur due to the irregular and fast heart rate characteristic of SVT. These palpitations can be intermittent and may vary in intensity, often causing discomfort and anxiety in patients.

Choice B Reason:

Weakness can be associated with SVT, but it is not as specific or common as palpitations. Weakness may occur due to the reduced cardiac output and decreased perfusion to the muscles during episodes of rapid heart rate. However, it is not the primary symptom that nurses would anticipate in patients with SVT.

Choice C Reason:

Shortness of breath is another symptom that can occur with SVT, especially during prolonged episodes. The rapid heart rate can lead to decreased efficiency in blood circulation, causing the patient to feel breathless. While shortness of breath is a significant symptom, palpitations are more directly associated with the diagnosis of SVT.

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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

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