A nurse is assisting with the plan of care for a client who had an upper endoscopy 1 hr ago. The nurse should place the priority on monitoring which of the following?

Sore throat

Abdominal bloating

Gag reflex

Belching

Answer and Explanation

The Correct Answer is C

Choice A rationale
While a sore throat can be a side effect of an upper endoscopy, it is not the priority for monitoring after the procedure.
Choice B rationale
Abdominal bloating can occur after an upper endoscopy, but it is not the priority for monitoring.
Choice C rationale
Monitoring the return of the gag reflex is a priority after an upper endoscopy. The gag reflex may be impaired due to the use of local anesthetics during the procedure. An impaired gag reflex increases the risk of aspiration.
Choice D rationale
Belching can occur after an upper endoscopy, but it is not the priority for monitoring

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Correct Answer is ["A","C","D"]

Explanation

Choice A rationale

Pain is a subjective experience and can be expressed both verbally and nonverbally. It is important for the nurse to be attentive to both types of expressions to effectively manage the patient’s pain.
Choice B rationale
While it is true that opioids should be used with caution due to the risk of addiction, this statement can be misleading. Opioids are often necessary for managing postoperative pain, and the risk of addiction is low when they are used appropriately and under medical supervision.
Choice C rationale
Considering the patient’s individual expression of pain is crucial in pain management. Pain is a subjective experience and can vary greatly between individuals. Tailoring pain management strategies to the individual patient can improve pain control.
Choice D rationale
Using a pain scale is a common and effective way to monitor the severity of a patient’s pain. It provides a quantifiable measure of pain that can be used to guide treatment decisions.

A. Increase fiber intake B. CT of the abdomen with contrast C. Flexible sigmoidoscopy D. Change IV fluids to 0.9% sodium chloride with KCl E. Type and crossmatch blood F. Administer IV piperacillin-tazobactam

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"C"}}

Explanation

• Increase fiber intake: This is nonessential at this time. While a high-fiber diet can help prevent future episodes of diverticulitis, it won’t help in the acute phase, especially when the client is unable to eat or drink without vomiting.
• CT of the abdomen with contrast: This is an anticipated action. A CT scan can help confirm the diagnosis of diverticulitis and assess the severity of the condition.
• Flexible sigmoidoscopy: This is an anticipated action. A flexible sigmoidoscopy can help visualize the diverticula and assess the extent of the inflammation.

• Change IV fluids to 0.9% sodium chloride with KCl: This is an anticipated action. The client is likely dehydrated due to vomiting and unable to take oral fluids, so IV hydration is necessary. The client’s potassium level is at the lower end of the normal range, so adding KCl to the IV fluids can help prevent hypokalemia.
• Type and crossmatch blood: This is an anticipated action. The client has a positive stool occult blood test and a lower than normal hemoglobin and hematocrit, suggesting that he may be experiencing bleeding. It’s important to have blood ready for a transfusion if necessary.
• Administer IV piperacillin-tazobactam: This is contraindicated. Piperacillin-tazobactam is a penicillin-based antibiotic, and the client has a known allergy to penicillin. Another class of antibiotics should be used. Please note that these are potential actions and the healthcare provider should be informed immediately for further evaluation and management. It’s important to continue following the provider’s prescriptions and closely monitor the client’s condition.

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A nurse is assisting with the plan of care for a client who had an upper endoscopy 1 hr ago. The nurse should place the priority on monitoring which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a postoperative patient. When helping to manage the patient’s pain, which of the following principles should the nurse apply? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

A nurse is caring for a 45-year-old male client in the emergency department who reports severe abdominal pain. Exhibits Based on the information provided, which of the following provider’s prescriptions are anticipated, nonessential, or contraindicated for the client? Select one response per row.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"C"}}

Explanation

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