Nursing Actions for Procedures

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Questions and Answers

What is the primary reason for maintaining the client on NPO status for 4 to 8 hours prior to the procedure?

Prevent allergic reactions to anesthetic agents

Facilitate faster recovery postprocedure

Ensure the effectiveness of preprocedure medications

Reduce the risk of aspiration when the cough reflex is blocked (correct)

Which nursing action is essential during the postprocedure phase for older adult clients?

Discharging the client as soon as they regain consciousness

Administering additional sedatives to manage anxiety

Monitoring for the return of the gag reflex and ability to swallow (correct)

Encouraging the client to eat solid foods immediately

What potential risk increases for older adult clients during sedation?

Improved gag reflex responsiveness

Faster recovery from anesthesia

Respiratory arrest due to respiratory insufficiency (correct)

Increased risk of respiratory infection

Why is it important to allow adequate time for the cough and gag reflex to return?

To prevent aspiration while the client swallows Signup and view all the answers

Which symptom might indicate a significant complication after bronchoscopy?

Productive cough with a large volume of sanguineous sputum Signup and view all the answers

What comfort measure can be suggested to a client experiencing throat soreness postprocedure?

Using throat lozenges or gargling with salt water Signup and view all the answers

What vital sign assessment is crucial during the recovery period post-procedure?

Respiratory rate and oxygenation status Signup and view all the answers

What should be performed before resuming oral intake after bronchoscopy?

Check the presence of a cough and gag reflex Signup and view all the answers

What is the primary nursing action to manage laryngospasm during recovery?

Continuously monitor for respiratory distress Signup and view all the answers

Which are the appropriate nursing actions to take if a client is at risk for pneumothorax?

Assess breath sounds and oxygen saturation Signup and view all the answers

What should be done to prevent aspiration in a patient post-bronchoscopy?

Withhold oral fluids or food until the gag reflex returns Signup and view all the answers

What equipment should be readily available for a patient undergoing a bronchoscopy?

Resuscitation equipment Signup and view all the answers

Which nursing action is necessary after a client aspirates oral secretions?

Perform suctioning of the airway as needed Signup and view all the answers

What is the primary purpose of thoracentesis?

To obtain specimens for diagnostic evaluation Signup and view all the answers

Which of the following conditions can lead to transudative pleural effusion?

Heart failure Signup and view all the answers

What technique is recommended to decrease the risk of complications during thoracentesis?

Using ultrasound for guidance Signup and view all the answers

Which symptom is commonly associated with large pleural effusions?

Shortness of breath Signup and view all the answers

What abnormal finding in the effusion area might indicate the presence of fluid?

Dull percussion sounds Signup and view all the answers

Which of the following actions is critical in ensuring client safety during the thoracentesis procedure?

Monitoring vital signs and oxygen saturation throughout the procedure Signup and view all the answers

What is the maximum amount of fluid that can be safely removed during a thoracentesis at one time?

1 L Signup and view all the answers

Which position should the client maintain during the thoracentesis procedure?

Sitting upright with arms and shoulders supported Signup and view all the answers

What should be done immediately after collecting the fluid during a thoracentesis?

Label specimens at the bedside for identification Signup and view all the answers

During the thoracentesis procedure, which of the following sensations might a client experience?

A sensation of pressure with needle insertion and fluid removal Signup and view all the answers

What is an indication of a pneumothorax that a nurse should monitor for after a thoracentesis?

Asymmetry of the chest wall Signup and view all the answers

Which nursing action is vital for assessing complications following thoracentesis?

Watch for rapid shallow respirations. Signup and view all the answers

What finding would most likely suggest a mediastinal shift after the procedure?

Deviated trachea towards the unaffected side Signup and view all the answers

What should the nurse assess for to evaluate the client's respiratory status after thoracentesis?

Breath sounds on the unaffected side Signup and view all the answers

What immediate action should be taken if diminished breath sounds are detected on the side of thoracentesis?

Prepare for a possible chest x-ray. Signup and view all the answers

What is a potential consequence of moving the client during a procedure?

Increased chance of hemoptysis Signup and view all the answers

What nursing action should be prioritized to prevent infection during a procedure?

Ensure sterile technique is maintained Signup and view all the answers

Which laboratory result would be most indicative of potential bleeding in a client?

Reduced Hgb level Signup and view all the answers

Which parameter should be monitored closely after a procedure to assess for signs of hemoptysis?

Client's temperature Signup and view all the answers

What nursing action should be taken if a client shows signs of hypotension post-procedure?

Notify the physician of the finding Signup and view all the answers

Study Notes

Preprocedure Nursing Actions

Assess client for allergies to anesthetics or anticoagulants.
Ensure client signs consent form before procedure.
Remove dentures, if applicable.
Maintain client on NPO status (4-8 hours) to reduce aspiration risk.
Administer pre-procedure medications (e.g., anxiolytic, atropine, viscous lidocaine, local anesthetic throat spray).

Intraprocedure Nursing Actions

Position client in sitting or supine position.
Assist with specimen collection and labeling; ensure prompt delivery to the lab.
Continuously monitor vital signs, respiratory pattern, and oxygenation.
- Note: Sedation in older adults with respiratory insufficiency can lead to respiratory arrest.

Postprocedure Nursing Actions

Continuously monitor respirations, blood pressure, pulse oximetry, heart rate, and level of consciousness.
Assess level of consciousness; older adults may experience confusion/lethargy due to medications.
Assess gag reflex and swallowing ability before oral intake.
Allow adequate time for gag reflex return before oral intake.
- Note: Gag reflex return may be slower in older adults receiving local anesthesia due to impaired laryngeal reflex.
Offer ice chips and then fluids once the gag reflex returns.
Monitor for fever, productive cough, significant hemoptysis (a small amount of blood-tinged sputum is expected), and hypoxemia.
Be prepared to manage unexpected responses, aspiration, and laryngospasm.
Provide oral hygiene.
Encourage coughing and deep breathing every 2 hours for older adults (due to increased risk of respiratory infections and pneumonia).
Discharge only when adequate cough reflex and respiratory effort are present.

Client Education

Gargling with salt water or using throat lozenges can relieve throat soreness.

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Description

This quiz covers essential nursing actions before, during, and after medical procedures. It includes assessing client readiness, monitoring vital signs, and managing post-procedure care effectively. Test your knowledge on the critical steps to ensure patient safety and care.