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 A
Explanation
Choice A Reason:
After a Billroth I procedure, where the stomach is anastomosed directly to the duodenum, some patients may experience diarrhea and feelings of fullness due to the direct passage of food into the small intestine without the buffering effect of the pyloric valve.
Choice B reason:
Gastric reflux and belching are not typically associated with a Billroth I procedure.
Choice C reason:
Persistent feelings of hunger and thirst are not common adverse effects associated specifically with a Billroth I procedure.
Choice D reason:
Constipation or bowel incontinence are not typically associated with a Billroth I procedure, as this surgery involves the upper gastrointestinal tract.
Correct Answer is A
Explanation
Choice A reason:
The urea breath test is typically used to diagnose Helicobacter pylori (H. pylori) infection in the stomach. H. pylori can lead to gastritis and ulcers, which can interfere with nutrient absorption and contribute to imbalanced nutrition.
Choice B reason:
Impaired dentition related to gingivitis is not directly related to the need for a urea breath test. This diagnosis pertains to dental health, not gastric health.
Choice C reason:
Diarrhea related to Clostridium difficile infection is not directly related to the need for a urea
breath test. This diagnosis pertains to a bacterial infection in the colon, not H. pylori infection in the stomach.
Choice D reason:
Risk for impaired skin integrity related to peptic ulcers is also not directly related to the need for a urea breath test. This diagnosis pertains to potential skin breakdown due to ulcers, not the
assessment of H. pylori infection.
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