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Zorluk: ZorReduction of Risk Potential

A client arrives at the medical-surgical unit after undergoing a flexible bronchoscopy with a transbronchial biopsy under conscious sedation. To reduce the risk of potential physiological complications, which actions should the nurse include in the client's immediate care plan? Select all that apply.

  1. Withhold all oral food and fluids until the return of the client's gag and swallow reflexes is clinically verified.Cevap
  2. B
    Delegate the initial post-procedure auscultation of lung sounds to the unlicensed assistive personnel to ensure frequent monitoring.
  3. Monitor for sudden onset of pleuritic chest pain, asymmetrical chest wall expansion, and tracheal deviation.Cevap
  4. D
    Position the client completely flat in bed for the first 4 hours to minimize the risk of post-procedure hypotension.
  5. E
    Notify the rapid response team if a post-procedure arterial blood gas analysis demonstrates a PaCO2 of 42 mm Hg.
  6. Assess for signs of laryngeal edema, such as inspiratory stridor or increasing hoarseness, which may threaten airway patency.Cevap

Cevap

The correct actions are to withhold oral intake until the gag reflex returns, monitor for signs of a pneumothorax (chest pain, asymmetrical expansion), and assess for laryngeal edema (stridor, hoarseness).
The correct interventions focus on protecting the airway and identifying life-threatening complications early. Verifying the gag reflex prevents aspiration, as topical anesthetics numb the throat. Monitoring for pleuritic chest pain and asymmetrical expansion detects a pneumothorax, a known severe complication of a transbronchial biopsy. Assessing for stridor and hoarseness ensures early recognition of laryngeal edema, which can rapidly compromise the airway.

Adım Adım Çözüm

1
Identify the procedure and its associated physiological risks.
The client underwent a bronchoscopy with a transbronchial biopsy under conscious sedation. Primary risks include aspiration (due to topical anesthetics), pneumothorax (due to the biopsy puncturing the pleura), and airway edema (due to instrumentation trauma).
Understanding procedure-specific risks is essential for prioritizing focused post-operative assessments.
2
Evaluate the options related to airway protection.
Withholding oral intake until the gag reflex returns actively prevents aspiration. Assessing for stridor detects impending airway compromise. Positioning the client flat is contraindicated as it increases aspiration risk and limits diaphragmatic excursion.
Airway patency is always the highest clinical priority following procedures involving the respiratory tract.
3
Evaluate the options related to breathing and gas exchange.
Monitoring for asymmetrical chest expansion identifies a pneumothorax, a major complication of a transbronchial biopsy. Interpreting a PaCO2 of 42 mm Hg as an emergency is incorrect, as this is a normal physiological value.
Breathing complications must be quickly identified, but normal baseline findings must be recognized to prevent inappropriate interventions.
4
Evaluate the option related to delegation and care management.
Delegating initial post-procedure lung auscultation to a UAP is outside their scope of practice.
The Registered Nurse must perform initial assessments to establish a clinical baseline and exercise nursing judgment.

Anahtar Kavram

Post-Bronchoscopy Complication Prevention and Monitoring
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Konular

Reduction of Risk Potential

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