A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next?

Correct Answer: C

Rationale: The correct answer is C: Assess the client's gag reflex before giving any food or water. After a bronchoscopy, the client's gag reflex may be compromised, increasing the risk of aspiration. Assessing the gag reflex is crucial to ensure the client can safely swallow without the risk of choking or aspirating. This step is essential before providing any food or water to prevent potential complications. Incorrect Choices: A: Calling the primary health care provider for food and water is unnecessary as the nurse can make this decision based on assessment. B: Providing ice chips instead of water does not address the need for assessing the gag reflex before giving any form of intake. D: Letting the client have a small sip without assessing the gag reflex first can pose a risk of aspiration if the reflex is impaired.

Correct Answer: B

Rationale: The correct answer is B: Alanine aminotransferase (ALT): 180 U/L. Elevated ALT levels indicate liver damage, a potential side effect of isoniazid. This is crucial to report immediately to the primary health care provider to assess liver function and adjust medication if needed. A: Albumin levels may fluctuate due to various factors but are not typically urgent in this context. C: RBC count within normal range, not directly related to isoniazid therapy. D: WBC count slightly elevated but not a priority unless there are other concerning symptoms.

Correct Answer: D

Rationale: The correct answer is D. Chemotherapy alone is generally less effective for laryngeal cancer compared to surgical treatment, radiation therapy, or combinations thereof. A (surgical treatment) and C (radiation therapy with surgery) are more successful. B (radical neck dissection) is a specific surgical approach but still more effective than chemotherapy alone.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Oral temperature 101.2°F. The rationale behind this choice is that an elevated temperature could indicate an infection, which is particularly concerning for a client with COPD who has not received flu or pneumonia vaccinations. Fever can be a sign of respiratory infection, which can exacerbate COPD symptoms and lead to complications. Option A) Blood pressure 152/84 is not the most relevant parameter to report in this situation. While elevated blood pressure can be a concern, it is not directly related to the client's respiratory condition and lack of vaccinations. Option B) Respiratory rate 27/minute is elevated but not as critical to report as the elevated temperature. Respiratory rate alone may not necessarily indicate an acute issue in this context. Option C) Heart rate 92/minute is within a normal range and is not as urgent to report as the elevated temperature. While heart rate can be affected by respiratory conditions, in this case, the temperature is a more immediate concern. Educationally, understanding the rationale behind choosing the correct vital sign to report is crucial for nursing assistants caring for clients with respiratory conditions. Recognizing the significance of changes in vital signs and their implications on specific health conditions is essential for providing timely and appropriate care to clients. It highlights the importance of comprehensive assessment skills and the ability to prioritize findings based on the client's individual health needs.

Correct Answer: D

Rationale: Palpation is a crucial assessment technique in examining the respiratory system. In this context, the correct answer is D) Limited chest expansion. Palpation involves using hands to feel for abnormalities or changes in the chest wall movement. Limited chest expansion can indicate conditions like pneumonia, pleural effusion, or obstructive lung diseases. Option A) Stridor is a high-pitched sound heard during inspiration and indicates upper airway obstruction, which is typically assessed through auscultation, not palpation. Option B) Finger clubbing is a physical sign where fingertips become rounded and the nail beds angle downwards due to chronic hypoxia. This is assessed visually and by palpating the fingertips, not through chest palpation. Option C) Tracheal deviation is a sign of tension pneumothorax or mass effect in the chest, which is assessed by inspection and palpation of the trachea, not chest wall palpation. Educationally, understanding the correct assessment techniques and their indications is crucial for healthcare professionals to accurately diagnose and manage respiratory conditions. Palpation skills are essential for detecting subtle changes in chest wall movement and guiding further diagnostic tests and interventions. This question reinforces the importance of differentiating assessment techniques based on the specific clinical presentation to provide optimal patient care.