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Difficulty: MediumReduction of Risk Potential

A nurse is assessing a client who has just been transferred to the medical-surgical unit following a flexible bronchoscopy with a tissue biopsy. Which of the following assessment findings indicate a potential complication that requires immediate intervention? Select all that apply.

  1. High-pitched inspiratory stridorAnswer
  2. Asymmetrical chest wall expansionAnswer
  3. C
    Absence of the gag reflex
  4. Coughing up frank red bloodAnswer
  5. E
    Small amounts of blood-tinged sputum

Answer

The findings that require immediate intervention are high-pitched inspiratory stridor, asymmetrical chest wall expansion, and coughing up frank red blood.
The correct findings represent life-threatening complications of a bronchoscopy and biopsy. High-pitched inspiratory stridor indicates laryngospasm or airway edema, which is an airway emergency. Asymmetrical chest expansion strongly suggests a pneumothorax, a complication that can occur if the pleura is accidentally punctured during the biopsy. Coughing up frank, bright red blood indicates active, severe hemorrhage from the biopsy site. All of these require immediate intervention to secure the client's airway, breathing, and circulation.

Step-by-Step Solution

1
Identify the procedure performed and its inherent clinical risks.
The client underwent a flexible bronchoscopy with a tissue biopsy.
Recognizing the procedure helps anticipate specific physiological complications such as airway compromise, pneumothorax, and hemorrhage.
2
Differentiate between expected post-procedure findings and signs of physiological decompensation.
An absent gag reflex and small amounts of blood-tinged sputum are expected. Stridor, asymmetrical chest expansion, and coughing up frank blood are abnormal.
Effective risk reduction requires the nurse to recognize subtle and overt indicators of impending emergencies.
3
Select the assessment findings that represent potential emergencies requiring immediate action.
Stridor (indicating airway obstruction), asymmetrical chest expansion (indicating pneumothorax), and frank red blood (indicating hemorrhage) are selected.
These findings directly compromise the airway, breathing, or circulation (ABCs) and take highest priority.

Key Concept

Reduction of Risk Potential: Post-Procedure Complications
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Topics

Reduction of Risk Potential

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