Examkin

Question

Difficulty: MediumReduction of Risk Potential

A nurse is formulating a plan of care for a client who has just returned to the nursing unit following a bronchoscopy with a transbronchial lung biopsy under conscious sedation. Which nursing interventions should be included in the plan of care to reduce the risk of post-procedure complications? Select all that apply.

  1. Withhold all oral food and fluids until the return of the client's gag reflex is verified.Answer
  2. B
    Position the client flat and supine to maintain airway alignment while recovering from sedation.
  3. C
    Assign the unlicensed assistive personnel (UAP) to obtain the immediate post-procedure vital signs.
  4. Assess respiratory effort, continuous oxygen saturation, and bilateral lung sounds.Answer
  5. E
    Notify the healthcare provider immediately if the client's post-procedure arterial blood gas (ABG) reveals a PaCO2 of 42 mm Hg.
  6. Reassure the client that a small amount of blood-streaked sputum is an expected finding.Answer

Answer

The appropriate risk-reduction interventions are to withhold all oral intake until the gag reflex returns, assess the respiratory status continuously, and reassure the client that a small amount of blood-streaked sputum is normal.
Appropriate risk reduction following a bronchoscopy prioritizes airway safety by delaying oral intake until the gag reflex returns, monitoring closely for pneumothorax through frequent lung assessments, and applying correct clinical judgment by recognizing that minor blood-tinged sputum is an expected consequence of a lung biopsy.

Step-by-Step Solution

1
Analyze the specific procedure and identify the associated physiological risks.
The client underwent a bronchoscopy with a transbronchial biopsy under conscious sedation. The primary risks include aspiration, pneumothorax, hypoxia, and severe hemorrhage.
Identifying procedure-specific risks is essential for determining the most appropriate monitoring and complication prevention strategies.
2
Evaluate each intervention to determine if it directly mitigates the identified risks within the nursing scope of practice.
Withholding fluids successfully prevents aspiration, assessing lung sounds rapidly detects pneumothorax, and recognizing blood-streaked sputum as an expected finding prevents unnecessary patient alarm.
Interventions must be clinically accurate and directly address the physiological vulnerabilities created by the procedure.
3
Identify contraindicated actions and incorrect clinical interpretations among the distractors.
Supine positioning, delegating initial post-operative vital signs to a UAP, and treating a normal PaCO2 level (42 mm Hg) as an emergency are all incorrect and potentially unsafe actions.
These actions either increase the risk of complications (such as aspiration or missed clinical instability) or demonstrate poor interpretation of standard diagnostic data.

Key Concept

Post-procedure care and complication prevention following an invasive respiratory procedure (bronchoscopy with biopsy).
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic