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 ["3.6"]
Explanation
- To calculate the dose of Ceclor in mg, multiply the weight in kg by the dosage in mg/kg/day and divide by the number of doses per day.
- To convert pounds to kg, divide by 2.2.
- To calculate the volume of Ceclor in mL, divide the dose in mg by the concentration in mg/mL.
- Convert 66 pounds to kg: 66 / 2.2 = 30 kg
- Calculate the dose of Ceclor in mg: 30 x 45 / 3 = 450 mg
- Calculate the volume of Ceclor in mL: 450 / 125 = 3.6 mL
- The nurse would administer 3.6 mL per dose.
Correct Answer is A
Explanation
Choice A reason:
Asterixis is a characteristic sign of hepatic encephalopathy, characterized by a flapping tremor of the hands. It is associated with liver dysfunction and is indicative of impaired ammonia metabolism in the brain.
Choice B reason:
Fetor hepaticus refers to a musty, sweet odor of the breath that is associated with severe liver disease. It is not related to the flapping tremor observed in this case.
Choice C reason:
Palmar erythema is a reddening of the palms and is associated with various conditions, including liver disease. However, it is not the sign described in the scenario.
Choice D reason:
Constructional apraxia is a neurological deficit characterized by difficulty in copying or constructing simple drawings or designs. It is not related to the flapping tremor seen in hepatic encephalopathy.
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