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Soru

Zorluk: KolayReduction of Risk Potential

Following a bronchoscopy utilizing topical throat anesthesia, a client is resting in the observation area and requests a glass of water. Which specific nursing assessment must be completed first to ensure the client's safety?

  1. Determine the return of the gag reflex.Cevap
  2. B
    Auscultate all lung fields for diminished breath sounds.
  3. C
    Measure the client's current oxygen saturation on room air.
  4. D
    Assist the client into a completely flat, supine position.

Cevap

The nurse must determine the return of the gag reflex before offering any oral fluids to prevent aspiration.
Topical anesthesia used during a bronchoscopy temporarily paralyzes the vocal cords and numbs the pharynx, suppressing the normal gag and swallow reflexes. To reduce the risk of potential complications, specifically aspiration, the nurse must verify that the gag reflex has returned before giving the client any food or fluids.

Adım Adım Çözüm

1
Analyze the clinical scenario and the effects of the procedure.
The client underwent a bronchoscopy using topical anesthesia, which temporarily numbs the throat and vocal cords.
Understanding the physiological impact of the procedure identifies potential immediate risks to the client.
2
Evaluate the client's request against physiological safety.
The client is asking for water. Without an intact gag reflex, swallowing fluids can lead to fluid entering the trachea instead of the esophagus.
Drinking fluids prematurely poses a severe risk for aspiration pneumonia or airway compromise.
3
Select the priority nursing intervention.
The nurse must check the gag reflex (often by gently touching the back of the throat with a tongue depressor or cotton swab) before providing anything by mouth.
Confirming the return of the gag reflex provides objective evidence that the client's airway is protected during swallowing.

Anahtar Kavram

Post-Procedure Aspiration Prevention
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Konular

Reduction of Risk Potential

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