A nurse is caring for a client diagnosed with acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

A. Level of consciousness:

While assessing the client's level of consciousness is important, it is not the top priority after an EGD procedure unless there are specific signs of neurological distress. Monitoring for signs of sedation or anesthesia recovery is typically part of post-procedure care.

B. Gag reflex:

This is the correct answer. The nurse should prioritize assessing the gag reflex, as the procedure involves passing a flexible tube through the mouth and down the esophagus. Ensuring the return of the gag reflex is essential to prevent aspiration and ensure the client's safety.

C. Pain:

Pain assessment is important, but it is usually addressed after confirming airway protection and ensuring the absence of complications such as bleeding or perforation.

D. Nausea:

While nausea is a possible post-procedure symptom, assessing the gag reflex and monitoring for signs of complications take precedence over managing nausea in the immediate post-procedure period.

A. Encourage weight lifting during physical therapy:

Encouraging weight lifting or strenuous physical activities might not be advisable for individuals with advanced cirrhosis. Engaging in intense physical activity could potentially strain the liver or increase the risk of injury or bleeding, which is already heightened in individuals with cirrhosis.

B. Measure the client's abdominal girth:

Monitoring the client's abdominal girth is essential because cirrhosis can lead to the accumulation of fluid in the abdomen, known as ascites. Changes in abdominal girth can indicate the progression or resolution of ascites, guiding treatment and interventions.

C. Administer warfarin:

Administering warfarin, an anticoagulant, might not be ideal in cirrhosis due to the increased risk of bleeding. Liver dysfunction in cirrhosis can impair the production of clotting factors, increasing the risk of bleeding complications.

D. Administer furosemide:

Furosemide, a diuretic, can be utilized in managing ascites by promoting the elimination of excess fluid. However, its use requires careful monitoring, considering the electrolyte balance and potential adverse effects, especially in individuals with liver impairment.

E. Implement a low-sodium diet:

A low-sodium diet is crucial in managing cirrhosis-related complications, particularly ascites and edema. Sodium restriction helps reduce fluid retention, lessening the burden on the liver and alleviating symptoms associated with fluid accumulation.