A nurse is caring for a client in the emergency room.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Rationale:
A. Hypertonic solutions, like TPN with 25% dextrose, can irritate peripheral veins and cause phlebitis. Administering them through a central line allows rapid dilution in a large volume of blood, reducing vein irritation and promoting safe infusion.
B. Blood glucose monitoring is not dependent on the line type; it is done via peripheral blood samples.
C. The infusion rate is determined by the prescribed therapy, not by whether a central line is used.
D. Central lines do not decrease the risk of infection; in fact, they carry a higher risk of central line–associated bloodstream infections compared with peripheral lines.

Rationale:
A. Pain assessment is important but not the immediate priority following an EGD. Discomfort is expected after the procedure, yet it does not pose the greatest risk to airway safety.

B. Nausea should be monitored, especially since sedation and irritation of the upper GI tract can cause vomiting, but this is not the most critical concern immediately after the procedure.

C. The gag reflex must be assessed first because topical anesthetics used during the EGD suppress the swallowing and protective airway reflexes. If oral fluids or food are given before the gag reflex returns, the client is at high risk for aspiration, which can lead to pneumonia or airway obstruction. Ensuring the gag reflex has returned is the priority safety measure before advancing the diet or giving oral medications.

D. Level of consciousness should also be assessed, since sedatives are commonly used during the procedure. However, the risk of aspiration from an absent gag reflex presents a more immediate threat to life and therefore takes priority.