NCLEX-RNReduction of Risk PotentialEasy
A client returns to the unit after a bronchoscopy in which the throat was sprayed with topical anesthetic. Which action should the nurse take before offering the client oral fluids?
- AAssess for return of the gag reflex
- BCheck pulse oximetry only
- CAssist the client to a high Fowler's position and offer ice chips immediately
- DAuscultate bowel sounds in all four quadrants
Show answer & explanationAnswer & explanation
Correct answer: A. Assess for return of the gag reflex
Topical anesthesia used during bronchoscopy numbs the throat and suppresses the gag reflex, increasing the risk of aspiration if oral intake occurs too soon. The nurse must confirm the gag reflex has returned before allowing food or fluids.
Why the other options are wrong
- B. Oxygen saturation alone does not indicate whether the client can safely swallow.
- C. Offering fluids before gag reflex returns risks aspiration regardless of positioning.
- D. Bowel sounds are unrelated to airway protection after bronchoscopy.
Post-Bronchoscopy Care
After bronchoscopy with topical throat anesthesia, the client must remain NPO until the gag reflex returns to prevent aspiration.
- Topical anesthetic numbs the pharynx
- Aspiration risk exists until gag reflex returns
- Also monitor for hemoptysis, laryngospasm, and pneumothorax
Memory trick: No gag, no grub