A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure.
Which of the following assessments is the nurse's priority?
Level of consciousness
Gag reflex
Nausea
Pain
The Correct Answer is B
Choice A reason:
While assessing the client's level of consciousness is important, it is not the priority after an EGD procedure. Ensuring the client's airway and protective reflexes is more crucial.
Choice B reason:
This is the correct answer. After an EGD, the client may have residual effects from sedation. Assessing the gag reflex helps ensure that the client's airway is protected.
Choice C reason:
Nausea is a common side effect after an EGD, but it is not the priority assessment. Ensuring the client's airway and safety come first.
Choice D reason:
Assessing pain is important for the client's comfort, but it is not the priority assessment after an EGD. Ensuring the client's airway and protective reflexes is more crucial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
While thirst can be a sign of dehydration, it is not specific to recurrence of a GI bleed.
Choice B reason:
This is the correct answer. Tachycardia (rapid heart rate), hypotension (low blood pressure), and tachypnea (rapid breathing) are signs of potential recurrence of a GI bleed and should be closely monitored.
Choice C reason:
Diaphoresis (excessive sweating) and sudden onset of abdominal pain could be indicative of various conditions, but they are not specific to recurrence of a GI bleed.
Choice D reason:
Tarry, foul-smelling stools are indicative of melena, which is a sign of a GI bleed. However, in this scenario, the bleeding has been controlled, so this is not an expected sign of recurrence.
Correct Answer is B
Explanation
Choice A reason:
Sudden thirst, unrelieved by oral fluid administration, may indicate dehydration, but it is not specific to a recurrence of upper GI bleeding.
Choice B reason:
This is the correct answer. Tachycardia (rapid heart rate), hypotension (low blood pressure), and tachypnea (rapid breathing) are signs of potential recurrence of upper GI bleeding and should be closely monitored.
Choice C reason:
Diaphoresis (excessive sweating) and sudden onset of abdominal pain could be indicative of various conditions, but they are not specific to a recurrence of upper GI bleeding.
Choice D reason:
Tarry, foul-smelling stools (melena) are indicative of upper GI bleeding. However, in this scenario, the bleeding has been controlled, so this is not an expected sign of recurrence.
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