Examkin

Soru

Zorluk: OrtaReduction of Risk Potential

Following an emergent bronchoscopy with a transbronchial lung biopsy, a 65-year-old client is transferred to the progressive care unit for continuous monitoring. Which of the following assessment findings indicate that the client is experiencing a severe post-procedure complication requiring immediate intervention? Select all that apply.

  1. A
    Arterial blood gas results showing a pH of 7.38, PaCO2 of 42 mm Hg, and PaO2 of 92 mm Hg
  2. Asymmetrical chest wall expansion with absent breath sounds on the biopsied sideCevap
  3. A steady increase in heart rate to 118 beats/min accompanied by a narrowing pulse pressureCevap
  4. D
    An absent gag reflex 30 minutes after the conclusion of the procedure
  5. E
    Client resting in a semi-Fowler's position while reporting a mild, scratchy throat
  6. Expectoration of copious amounts of frank, bright red bloodCevap

Cevap

The findings that indicate a severe complication are asymmetrical chest wall expansion with absent breath sounds, tachycardia with a narrowing pulse pressure, and the expectoration of copious frank blood.
Following a transbronchial biopsy, the client is at severe risk for airway compromise, pneumothorax, and internal bleeding. Asymmetrical chest wall expansion with absent breath sounds is the hallmark presentation of a pneumothorax, meaning air has leaked into the pleural space. A steadily increasing heart rate combined with a narrowing pulse pressure represents the classic early compensatory mechanisms of hypovolemic shock, likely due to internal hemorrhage. Lastly, while minor blood-streaked sputum is expected as the biopsy site oozes slightly, expectorating copious amounts of frank, bright red blood indicates an active, uncontrolled airway hemorrhage that can quickly lead to asphyxiation and death.

Adım Adım Çözüm

1
Identify the primary physiological risks associated with the procedure.
A transbronchial biopsy involves puncturing lung tissue, which places the client at a high risk for pneumothorax and severe hemorrhage.
Understanding procedure-specific risks directs the nurse to assess for the most lethal complications.
2
Evaluate the clinical findings for signs of respiratory or hemodynamic instability.
Absent breath sounds with asymmetrical chest expansion point to a pneumothorax. Tachycardia with narrowing pulse pressure points to hypovolemic shock. Copious bright red blood indicates active airway hemorrhage.
Recognizing these acute deviations allows for rapid intervention in life-threatening scenarios.
3
Differentiate expected post-procedure effects from true emergencies.
Normal arterial blood gases, an absent gag reflex at 30 minutes, a semi-Fowler's position, and a scratchy throat are all expected or appropriate findings.
Recognizing expected outcomes prevents unnecessary interventions and alarm, allowing the nurse to focus on true physiological deterioration.

Anahtar Kavram

Post-Bronchoscopy Complication Recognition and Priority Action
Tahmini Süre:2m 0s
Bu soruyu puanla

Konular

Reduction of Risk Potential

Bu konudan daha fazla soru