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Difficulty: HardReduction of Risk Potential

A nurse is developing a post-procedure plan of care for a 54-year-old client who has just returned to the medical-surgical unit following a flexible bronchoscopy with a transbronchial biopsy under conscious sedation. Which of the following nursing actions should be included to reduce the risk of potential complications? Select all that apply.

  1. Assess for the return of the gag and swallow reflexes prior to offering any oral fluids or ice chips.Answer
  2. Auscultate bilateral lung fields to monitor for diminished or asymmetrical breath sounds.Answer
  3. C
    Maintain the client in a strictly flat, supine position for the first two hours to prevent hypotension.
  4. D
    Delegate the initial, immediate post-procedure vital sign measurements and respiratory assessment to the unlicensed assistive personnel.
  5. E
    Administer intravenous sodium bicarbonate if a post-procedure arterial blood gas shows a pH of 7.317.31 and a PaCO 2_2 of 4949 mm Hg.
  6. Notify the healthcare provider immediately if the client begins expectorating frank, bright red blood.Answer

Answer

The correct actions are assessing for the return of the gag reflex before allowing oral intake, auscultating bilateral lung fields for breath sounds, and notifying the provider immediately if frank, bright red blood is expectorated.
Following a transbronchial biopsy under conscious sedation, the client is highly vulnerable to airway compromise and physiological decompensation. Assessing the gag reflex directly prevents aspiration of fluids into the lungs. Auscultating breath sounds is a critical assessment for detecting a pneumothorax, a known complication of lung biopsy. While blood-streaked sputum is a normal finding after tissue removal, expectorating frank, bright red blood indicates an active hemorrhage and requires immediate provider notification.

Step-by-Step Solution

1
Identify the procedure and its specific physiological risks.
The client had a bronchoscopy with a transbronchial biopsy under conscious sedation. Primary risks include aspiration (due to topical airway anesthesia), pneumothorax (due to lung tissue biopsy), hemorrhage (from the biopsy site), and respiratory depression (from sedation).
Understanding the exact mechanism of the procedure dictates the prioritized nursing assessments.
2
Evaluate the interventions aimed at airway and breathing protection.
Checking the gag reflex before giving fluids directly prevents aspiration. Auscultating lung sounds allows the nurse to detect a pneumothorax early (indicated by diminished or absent sounds on the affected side).
Airway and breathing are always the highest priority in post-sedation and airway-invasive procedures.
3
Differentiate between expected post-procedure findings and dangerous complications regarding bleeding.
Blood-streaked or pink-tinged sputum is normal as the biopsy site heals. However, frank, bright red blood indicates an uncontrolled hemorrhage and requires immediate intervention.
Nurses must be able to recognize when a symptom crosses the line from an expected side effect to an adverse event.
4
Identify the contraindicated actions in the distractors.
Supine positioning increases aspiration risk. Initial assessments on unstable/post-op clients cannot be delegated to UAPs. Mild respiratory acidosis from sedation is treated with respiratory stimulation (deep breathing), not chemical buffering like sodium bicarbonate.
Applying safe delegation, proper positioning, and accurate lab interpretation are core risk reduction strategies.

Key Concept

Post-bronchoscopy complication management focuses on preventing aspiration (checking gag reflex, proper positioning), detecting pneumothorax (auscultating lungs), monitoring for hemorrhage (differentiating frank blood from expected blood-tinged sputum), and managing expected transient sedation effects safely.
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Reduction of Risk Potential

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