A nurse is caring for a client following a bronchoscopy with moderate sedation. Which of the following actions should the nurse take? (Select all that apply.)

Choice A rationale A bronchoscopy involves passing a flexible tube through the mouth and into the airways, and moderate sedation is used to minimize discomfort. This can suppress the client's gag reflex, which is the body's protective mechanism to prevent aspiration. Assessing for the return of the gag reflex before offering oral intake is a critical safety measure to prevent food or fluid from entering the lungs. Choice B rationale Following a bronchoscopy, a nurse should listen to the client's breath sounds to assess for any adventitious sounds or diminished air entry. This is a crucial step to detect potential complications such as atelectasis (collapsed lung), bronchospasm, or fluid accumulation in the lungs. Normal breath sounds are expected, and any deviation can indicate a complication. Choice C rationale Monitoring a client's oxygen saturation with a pulse oximeter is essential after a bronchoscopy. The procedure can cause irritation and swelling of the airways, potentially leading to hypoxemia. The sedation used also has a depressive effect on respiration. Continuous monitoring ensures early detection and intervention if the client's oxygen levels drop below the normal range of 95% to 100%. Choice D rationale A bronchoscopy can cause minor trauma to the mucosal lining of the airways, leading to bleeding. The nurse should monitor the client for signs of bleeding, such as hemoptysis (coughing up blood) or bloody sputum. While a small amount of blood-tinged sputum is expected, excessive bleeding could indicate a more serious complication and requires immediate medical attention. Choice E rationale Assessing the client's puncture site is an action typically performed after a procedure involving an incision or needle puncture, such as a thoracentesis or central line insertion. A bronchoscopy is performed through the mouth or nose and does not involve an external puncture site. Therefore, this action is not relevant to post-bronchoscopy care. Choice F rationale A pneumothorax, or a collapsed lung, is a potential complication of a bronchoscopy, particularly if a biopsy was performed. It occurs when air leaks into the space between the lung and chest wall, causing the lung to collapse. The nurse should observe for manifestations such as sudden chest pain, shortness of breath, and decreased or absent breath sounds on the affected side.