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:
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.
Correct Answer is A
Explanation
Choice A reason:
Chronic blood loss is a common complication of ulcerative colitis. Inflammation and ulcers in the colon can lead to ongoing bleeding, resulting in iron deficiency anemia.
Choice B reason:
While intestinal malabsorption can occur in some gastrointestinal disorders, it is not a primary mechanism in ulcerative colitis. In ulcerative colitis, the main factor leading to anemia is chronic blood loss.
Choice C reason:
Dietary iron restrictions may exacerbate anemia in individuals with ulcerative colitis, but the primary cause of anemia in this condition is chronic blood loss.
Choice D reason:
Intestinal parasites are not a common factor in ulcerative colitis and are not a primary cause of anemia in this condition. Chronic blood loss is the main contributing factor.
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