A nurse is caring for a 64-year-old client who has just returned to the medical-surgical unit following a flexible bronchoscopy with a tissue biopsy of a suspicious right lung mass. The procedure was performed under moderate sedation. Which of the following nursing actions should the nurse include in the plan of care to reduce the client's risk for potential complications? Select all that apply.
- Withhold all oral foods and fluids until the return of the gag and swallow reflexes is verified.Answer
- Monitor the client closely for the development of stridor, wheezing, or asymmetrical breath sounds.Answer
- Instruct the client to report any new onset of shortness of breath or sharp chest pain immediately.Answer
- DPlace the client in a flat, supine position for the first two hours to minimize the risk of a post-procedure headache.
- EDelegate the initial evaluation of the client's gag reflex to the experienced unlicensed assistive personnel (UAP).
- FAttribute a new finding of mild tachycardia and a narrowing pulse pressure to expected post-procedure anxiety.
Answer
The correct actions include withholding oral intake until the gag reflex returns, monitoring for signs of airway compromise like stridor or asymmetrical breath sounds, and instructing the client to report sharp chest pain or dyspnea, which could indicate a pneumothorax.
The correct interventions focus directly on reducing the most immediate risks following a bronchoscopy with biopsy. Withholding oral intake prevents aspiration while the gag reflex is suppressed by topical anesthetics. Monitoring for stridor and asymmetrical breath sounds ensures early detection of airway edema or bronchospasm. Instructing the client to report sharp chest pain or shortness of breath facilitates the rapid identification of a pneumothorax, a known complication of lung biopsies.
Step-by-Step Solution
Key Concept
Post-Bronchoscopy Risk Reduction and Complication Management