What should the nurse prioritize when monitoring an older adult client immediately following a bronchoscopy?

Correct Answer: C

Rationale: The correct answer is C: Confirming the gag reflex. Immediately following a bronchoscopy, the nurse must prioritize confirming the gag reflex to ensure the client can protect their airway. This is crucial to prevent aspiration and respiratory complications. Observing for confusion (choice A) is important but not the priority in this situation. Auscultating breath sounds (choice B) is also important but confirming the gag reflex takes precedence. Measuring blood pressure (choice D) is not directly related to the immediate post-bronchoscopy monitoring.

Correct Answer: C

Rationale: The correct answer is C: Avoid speaking for extended periods. This instruction is important to prevent strain on the vocal cords and reduce the risk of aspiration or airway irritation post-extubation. Speaking after the removal of the endotracheal tube can potentially lead to complications. Step-by-step rationale: 1. Speaking can cause strain on the vocal cords, which may lead to hoarseness or damage. 2. It is essential to allow the airway to recover and prevent irritation or inflammation. 3. Resting the voice can aid in the healing process and reduce the risk of complications. 4. Incentive spirometer use (option B) is important for lung expansion but not directly related to vocal cord rest. 5. Vital signs monitoring (option D) is crucial but does not address vocal cord care or prevention of complications. 6. Resting in a side-lying position (option A) is not directly related to vocal cord rest or post-extubation care.

Correct Answer: B

Rationale: The correct answer is B: 480 mL. For a client with an ideal weight of 60 kg, the tidal volume should be set at 6-8 mL/kg of ideal body weight. Therefore, for a 60 kg individual, the tidal volume should be between 360-480 mL. B falls within this range and is the most appropriate choice. A: 300 mL is too low and would not provide adequate ventilation for a client of this weight. C: 800 mL is too high and could lead to overventilation and potential lung injury. D: 950 mL is also too high and poses the same risks as option C. In summary, B is the correct choice as it falls within the appropriate tidal volume range based on the client's ideal weight, while the other options are either too low or too high.

Correct Answer: B

Rationale: The correct answer is B: Nausea. In acute respiratory failure (ARF), the body may compensate by increasing respiratory rate, leading to respiratory alkalosis. This can cause nausea due to the altered pH levels affecting the chemoreceptors in the brain. Severe dyspnea (choice A) is a common symptom of ARF but does not specifically relate to nausea. Decreased level of consciousness (choice C) may indicate severe hypoxemia but is not a direct manifestation of ARF. Headache (choice D) is more commonly associated with conditions like hypoxia, hypercapnia, or respiratory acidosis in ARF.

Correct Answer: B

Rationale: The correct answer is B: Resonance. When assessing a client with chronic bronchitis, the healthcare provider should expect to hear resonant percussion sounds. This is because chronic bronchitis is characterized by inflammation and excess mucus production in the bronchial tubes, leading to airway obstruction. Resonance indicates normal lung tissue and air-filled spaces. Dullness (A) may suggest consolidation or fluid in the lungs, which is not typically associated with chronic bronchitis. Tympany (C) is a drum-like sound that can be heard over air-filled structures like the stomach, not typically expected in a lung assessment. Flatness (D) is heard over solid structures like the liver and would not be expected in a lung assessment for chronic bronchitis.