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?

<p>To prevent aspiration while the client swallows (A)</p> Signup and view all the answers

Which symptom might indicate a significant complication after bronchoscopy?

<p>Productive cough with a large volume of sanguineous sputum (C)</p> Signup and view all the answers

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

<p>Using throat lozenges or gargling with salt water (B)</p> Signup and view all the answers

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

<p>Respiratory rate and oxygenation status (B)</p> Signup and view all the answers

What should be performed before resuming oral intake after bronchoscopy?

<p>Check the presence of a cough and gag reflex (B)</p> Signup and view all the answers

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

<p>Continuously monitor for respiratory distress (C)</p> Signup and view all the answers

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

<p>Assess breath sounds and oxygen saturation (D)</p> Signup and view all the answers

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

<p>Withhold oral fluids or food until the gag reflex returns (C)</p> Signup and view all the answers

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

<p>Resuscitation equipment (D)</p> Signup and view all the answers

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

<p>Perform suctioning of the airway as needed (C)</p> Signup and view all the answers

What is the primary purpose of thoracentesis?

<p>To obtain specimens for diagnostic evaluation (A)</p> Signup and view all the answers

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

<p>Heart failure (B)</p> Signup and view all the answers

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

<p>Using ultrasound for guidance (C)</p> Signup and view all the answers

Which symptom is commonly associated with large pleural effusions?

<p>Shortness of breath (D)</p> Signup and view all the answers

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

<p>Dull percussion sounds (D)</p> Signup and view all the answers

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

<p>Monitoring vital signs and oxygen saturation throughout the procedure (B)</p> Signup and view all the answers

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

<p>1 L (C)</p> Signup and view all the answers

Which position should the client maintain during the thoracentesis procedure?

<p>Sitting upright with arms and shoulders supported (C)</p> Signup and view all the answers

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

<p>Label specimens at the bedside for identification (C)</p> Signup and view all the answers

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

<p>A sensation of pressure with needle insertion and fluid removal (D)</p> Signup and view all the answers

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

<p>Asymmetry of the chest wall (C)</p> Signup and view all the answers

Which nursing action is vital for assessing complications following thoracentesis?

<p>Watch for rapid shallow respirations. (C)</p> Signup and view all the answers

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

<p>Deviated trachea towards the unaffected side (D)</p> Signup and view all the answers

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

<p>Breath sounds on the unaffected side (A)</p> Signup and view all the answers

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

<p>Prepare for a possible chest x-ray. (B)</p> Signup and view all the answers

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

<p>Increased chance of hemoptysis (A)</p> Signup and view all the answers

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

<p>Ensure sterile technique is maintained (D)</p> Signup and view all the answers

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

<p>Reduced Hgb level (A)</p> Signup and view all the answers

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

<p>Client's temperature (C)</p> Signup and view all the answers

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

<p>Notify the physician of the finding (C)</p> Signup and view all the answers

Flashcards

Pre-procedure Nursing Actions

Actions taken before a medical procedure to prepare the patient. These include allergy checks, consent forms, removing dentures, and NPO status.

Intra-procedure Nursing Actions

Actions taken during a medical procedure, such as positioning, specimen collection, vital sign monitoring, and careful management of sedation especially in older adults.

Post-procedure Nursing Actions

Actions needed after a medical procedure like continuous monitoring, gag reflex and swallowing assessments, and encouraging coughing to prevent aspiration, infection.

Post-procedure monitoring

Continuous observation of vital signs, level of consciousness, gag reflex, and potential complications for the client after a medical procedure.

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Cough and Gag Reflex Monitoring

Observing the client's ability to cough and gag to ensure the client is ready to resume oral intake.

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Aspiration Risk Prevention

Keeping clients NPO prior to procedures and monitoring the cough and gag reflex to reduce the risk of inhaling food or fluids.

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Respiratory Issues in Older Adults

Older adults are more vulnerable to respiratory complications due to decreased cough effectiveness and secretion clearance. Sedation can also lead to respiratory arrest.

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Client Discharge Criteria

Adequate cough reflex/respiratory effort determined by nurse monitoring, before client discharge from the recovery room.

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Laryngospasm

Uncontrolled muscle contractions of the vocal cords that make breathing hard.

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How does laryngospasm impact breathing?

It causes difficulty breathing in (inhaling) due to the vocal cords closing off the airway.

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Pneumothorax after bronchoscopy

Collapsed lung that can happen after a rigid bronchoscopy procedure.

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Aspiration risk after procedure

The patient may inhale food or fluids into their lungs after a procedure.

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Preventing Aspiration

Keeping the patient NPO until their gag reflex returns.

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Thoracentesis

A procedure involving the insertion of a needle into the chest cavity to remove fluid, air, or to administer medication.

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Pleural Effusion

An abnormal build-up of fluid in the space between the lung and the chest wall (pleural space).

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Transudate vs. Exudate

Transudates are watery effusions due to pressure or low protein levels, while exudates are thicker effusions caused by inflammation.

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Empyema

A pleural effusion containing pus, usually caused by infection.

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Thoracentesis Risks

Possible complications include pneumothorax (collapsed lung), bleeding, infection, and injury to nearby organs.

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Thoracentesis Purpose

A procedure to remove fluid from the pleural space using a needle, often done to diagnose or treat conditions like pleural effusion or pneumothorax.

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Pre-Thoracentesis Positioning

The client should sit upright with their arms and shoulders raised and supported. Feet and legs should also be well-supported to maintain a stable position throughout the procedure.

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Thoracentesis Client Education

Inform the client to remain still during the procedure to avoid accidental needle injury. They should also avoid coughing or talking unless instructed by the provider.

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Thoracentesis Fluid Removal Limit

The maximum amount of fluid removed during a single thoracentesis is 1 liter. This prevents re-expansion pulmonary edema, a potentially dangerous complication.

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Thoracentesis Specimen Handling

Once collected, the aspirated fluid is labeled at the bedside and promptly sent to the laboratory for analysis.

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Mediastinal Shift

A condition where the structures in the chest cavity move to one side, often caused by fluid buildup or lung collapse.

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Pneumothorax

A collapsed lung, which can occur after a procedure like a thoracentesis when the lung is injured.

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Pneumothorax Signs

Indicators of a collapsed lung include diminished breath sounds, distended neck veins, chest wall asymmetry, respiratory distress, and cyanosis.

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Thoracentesis Post-procedure Care

After a thoracentesis, monitor vital signs, auscultate lungs for reduced breath sounds, encourage deep breathing, and obtain a chest x-ray.

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Thoracentesis Complications

Potential complications of a thoracentesis include mediastinal shift and pneumothorax.

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What is the main risk associated with Thoracentesis?

The main risk associated with Thoracentesis is a pneumothorax, which is a collapsed lung. This occurs when air leaks into the space between the lung and chest wall, causing the lung to collapse.

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How to monitor for bleeding after a thoracentesis?

To assess for possible bleeding after a thoracentesis, monitor vital signs like blood pressure and heart rate. Also, pay attention to the patient's hemoglobin levels, as a decrease indicates blood loss.

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What are the signs of infection after a Thoracentesis?

Signs of infection following a Thoracentesis include a fever, chills, increased white blood cell count, and redness or swelling at the puncture site.

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How to prevent infection during Thoracentesis?

Maintaining a sterile technique during the procedure minimizes the risk of bacterial contamination, thus lowering the chance of infection. This involves using sterile gloves, instruments, and a sterile environment.

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Why is cough monitoring important after a Thoracentesis?

Coughing after a thoracentesis can potentially cause complications, such as a pneumothorax (collapsed lung) or worsening of bleeding. Therefore, close monitoring is essential.

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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.

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