A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation.
Which of the following assessment findings is the nurse's priority?
Level of pain.
Gag reflex.
Warmth of extremities.
Temperature.
The Correct Answer is B
The nurse’s priority should be to assess the client’s gag reflex.
After an endoscopy with moderate (conscious) sedation, it is important to ensure that the client’s gag reflex has returned before allowing them to eat or drink.
Choice A is incorrect because while pain management is important, it is not the nurse’s priority in this situation.
Choice C is incorrect because the warmth of extremities is not the nurse’s priority in this situation.
Choice D is incorrect because temperature is not the nurse’s priority in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The priority intervention for a nurse planning care for a client who has status epilepticus is to administer diazepam intravenously to the client.
Diazepam is a benzodiazepine medication that can help stop seizure activity and is often used as a first-line treatment for status epilepticus.
Choice A is incorrect because while phenytoin can be used to treat seizures, it is not typically used as a first-line treatment for status epilepticus.
Choice C is incorrect because while providing oxygen can be an important intervention for clients experiencing seizures, it is not the priority intervention.
Choice D is incorrect because while turning the client to the lateral position during seizure activity can help prevent aspiration, it is not the priority intervention.
Correct Answer is C
Explanation
When administering packed RBCs, the tubing should be primed with 0.9% sodium chloride.
Transfusing each unit of blood over 5 hours (choice A) is not recommended as it may increase the risk of bacterial growth.
Packed RBCs should be transfused over 2 to 3 hours.
Changing the IV tubing after each unit of blood is transfused (choice B) is not necessary.
Administering the blood through a 22-gauge intravenous catheter (choice D) may not be appropriate as a larger gauge catheter is typically used for blood transfusions.
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