A client who is fully awake after a gastroscopy asks the nurse for something to drink.
After confirming that liquids are allowed, which assessment action should the nurse consider a priority before offering oral intake?

Provide thickened fluids with a straw.

Listen to bilateral lung and bowel sounds.

Check the client's Hypoglossal nerve and Vestibulocochlear cranial nerve function.

Check the client's Glossopharyngeal nerve and Vagus cranial nerve function.

Answer and Explanation

The Correct Answer is D

Choice A rationale: Providing thickened fluids with a straw is more related to swallowing difficulties and is not the priority in this context.

Choice B rationale: While assessing lung and bowel sounds is important, it's not directly related to offering oral intake after a gastroscopy.

Choice C rationale: Assessing the Hypoglossal nerve and Vestibulocochlear cranial nerve function isn't directly related to offering oral intake post-gastroscopy.

Choice D rationale: Checking the client's Glossopharyngeal nerve and Vagus cranial nerve function is crucial as these nerves play roles in swallowing, taste, and the gag reflex, which are important before allowing oral intake post-gastroscopy.

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Correct Answer is C

Explanation

Choice A rationale: Assessing the UOP is important, but not as urgent as correcting the potassium imbalance.

Choice B rationale: Obtaining a 12-lead ECG can help monitor the cardiac status, but it does not address the cause of the problem.

Choice C rationale: The PMHCP can order potassium replacement to prevent cardiac arrhythmias and other adverse effects of low potassium levels.

Choice D rationale: Stopping the regular insulin infusion can worsen the DKA and increase the risk of cerebral edema and coma.

A. a client with nausea, vomiting, and abdominal pain B. a client with chest tightness and heartburn C. a client with facial drooping and left-sided weakness D. a client with fatigue, fever, and productive cough

Correct Answer is C

Explanation

Choice A rationale: A client with nausea, vomiting, and abdominal pain may have gastroenteritis, food poisoning, or appendicitis, which are not directly related to the eyes.

Choice B rationale: A client with chest tightness and heartburn may have gastroesophageal reflux disease (GERD), angina, or myocardial infarction (MI), which are also not associated with the eyes.

Choice C rationale: A client with facial drooping and left-sided weakness may have a stroke, which is a medical emergency that requires immediate attention. An eye examination can help detect signs of stroke, such as pupil asymmetry, visual field defects, or eye movement abnormalities. A stroke can cause permanent brain damage or death if not treated promptly.

Choice D rationale: A client with fatigue, fever, and productive cough may have a respiratory infection, such as pneumonia or tuberculosis, which are unlikely to affect the eyes unless there is a systemic complication.

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A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority before offering oral intake?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with diabetic ketoacidosis (DKA) receiving intravenous (IV) regular insulin. The most recent potassium was 2.9 mEq/L. The nurse should take which priority action:

Correct Answer is C

Explanation

Which client should receive the pictured examination first?

Correct Answer is C

Explanation

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A client who is fully awake after a gastroscopy asks the nurse for something to drink.
After confirming that liquids are allowed, which assessment action should the nurse consider a priority before offering oral intake?