Safe, Effective Care Environment
62. The first nursing concern for a client following bronchoscopy should be to:
Safe, Effective Care Environment
62. The first nursing concern for a client following bronchoscopy should be to:
. Ambulate as soon as sedation wears off.
. Check for the return of the gag reflex.
. Teach how to use the incentive spirometer.
. Position the client on the unaffected side.
Test-Taking Tip
Priority: Which option, if not done, would cause greatest harm to the client?
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
Safe, Effective Care Environment
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Answer 1 is incorrect because this is a priority question. Ambulating after the sedation wears off is not wrong; it just is not the first concern. Answer 2 is correct because the throat will have been anesthetized to facilitate passage of the tube. If the gag reflex has not returned before food or fluid is given, the client may aspirate. Answer 3 is incorrect because teaching should have been done before the procedure. It is also not the first concern. Answer 4 is incorrect because no particular positioning is indicated following a diagnostic bronchoscopy.