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Difficulty: MediumReduction of Risk Potential

A nurse is caring for a client who recently returned to the clinical unit following a flexible bronchoscopy with a transbronchial biopsy under conscious sedation. The client is currently drowsy but opens their eyes to verbal stimuli. The client's pulse oximetry is 96%96\% on room air, and a routine post-procedure arterial blood gas (ABG) analysis reveals a pH of 7.407.40, PaCO2PaCO_2 of 4040 mm Hg, and PaO2PaO_2 of 8888 mm Hg. To effectively reduce the risk of post-procedure complications, which of the following actions should the nurse take first?

  1. A
    Position the client flat in a supine position to maintain spinal alignment and promote rest.
  2. B
    Prioritize the administration of prescribed intravenous opioid analgesics to treat a mild sore throat.
  3. C
    Apply supplemental oxygen via nasal cannula at 44 L/min to correct the client's hypoxemia.
  4. Withhold all oral food and fluids until the client demonstrates an intact gag reflex.Answer

Answer

The correct action is to withhold all oral food and fluids until the client demonstrates an intact gag reflex.
Following a bronchoscopy, the client's throat is typically numbed with a topical anesthetic to suppress the gag reflex and allow for the passage of the bronchoscope. Until this local anesthesia wears off and the gag reflex fully returns, the client is at a high risk for aspiration. Withholding all oral intake until this reflex is verified directly reduces the potential for this life-threatening pulmonary complication.

Step-by-Step Solution

1
Assess the client's current status and identify the nature of the recent procedure.
The client had a bronchoscopy under conscious sedation, which involves topical anesthesia to the throat, and is currently drowsy but stable.
Understanding the procedural interventions is necessary to anticipate specific post-operative risks.
2
Analyze the provided diagnostic data.
The pulse oximetry is 96%96\%, and the ABG values (pH 7.407.40, PaCO2PaCO_2 4040 mm Hg, PaO2PaO_2 8888 mm Hg) are within normal physiological limits.
Normal ABG values rule out acute respiratory failure or hypoxemia, eliminating the immediate need for supplemental oxygen interventions.
3
Evaluate the options based on the highest priority risk for this specific procedure.
The most significant immediate risk is pulmonary aspiration due to the suppressed gag reflex from the topical anesthetic.
Airway protection is the top priority in the immediate post-operative period following airway instrumentation.
4
Select the nursing action that directly mitigates this risk.
Withholding all oral intake until the gag reflex returns is selected as the priority intervention.
This directly prevents aspiration of food or fluids into the lungs while the protective airway reflexes are compromised.

Key Concept

Aspiration prevention and airway management following procedures involving topical airway anesthesia.
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Topics

Reduction of Risk Potential

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