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Difficulty: EasyReduction of Risk Potential

A 72-year-old client is recovering in the outpatient care unit following a bronchoscopy performed with moderate sedation. Which of the following actions should the nurse take to reduce the client's risk of complications? Select all that apply.

  1. Keep the client nothing by mouth (NPO) until the gag reflex returns.Answer
  2. Assess respiratory rate, oxygen saturation, and lung sounds frequently.Answer
  3. C
    Maintain the client in a flat, supine position to promote rest.
  4. D
    Delegate the initial post-procedure evaluation of the client's airway to the unlicensed assistive personnel.
  5. E
    Document any new onset of mild confusion as a normal expected finding due to the client's advanced age.

Answer

The nurse should keep the client NPO until the gag reflex returns and frequently assess the client's respiratory rate, oxygen saturation, and lung sounds.
Following a bronchoscopy, the local anesthetic used in the throat suppresses the gag reflex, creating a high risk for aspiration. Keeping the client NPO until this reflex returns is an essential risk-reduction strategy. Additionally, moderate sedation can cause respiratory depression, making the frequent monitoring of oxygenation and lung sounds absolutely critical to detect and manage complications early.

Step-by-Step Solution

1
Identify the primary physiological risks associated with a bronchoscopy and moderate sedation.
The main risks are aspiration (due to topical anesthetics depressing the gag reflex) and respiratory depression/hypoxia (from the sedative medications).
Understanding procedure-specific risks dictates which focused nursing assessments and interventions are required.
2
Evaluate the correct interventions for airway and breathing protection.
Keeping the client NPO prevents aspiration, and frequent respiratory assessment detects hypoxia early.
Airway and breathing are the highest priorities in post-operative and post-procedure care.
3
Analyze the remaining options to identify unsafe practices or clinical errors.
Supine positioning increases aspiration risk, initial airway assessments cannot be delegated, and sudden confusion is a sign of hypoxia, not normal aging.
Recognizing unsafe actions prevents adverse client outcomes and legal/ethical delegation breaches.

Key Concept

Post-procedure care, airway protection, and complication monitoring following moderate sedation.
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Topics

Reduction of Risk Potential

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