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 A
Explanation
The earliest indication of peritonitis in a patient undergoing peritoneal dialysis is often cloudy dialysis fluid when drained from the body.
Choice B is incorrect because an increased heart rate is not the earliest indication of peritonitis.
Choice C is incorrect because generalized abdominal pain is not the earliest indication of peritonitis.
Choice D is incorrect because fever is not the earliest indication of peritonitis.
Correct Answer is A
Explanation
This can help prevent dizziness and loss of balance, which are common symptoms of Ménière’s disease.
Choice B is not correct because range-of-motion exercises to the client’s neck every 4 hours are not a standard intervention for Ménière’s disease.
Choice C is not correct because aspirin is not always the recommended medication for headaches associated with Ménière’s disease.
Choice D is not correct because limiting fluid intake is not a standard intervention for Ménière’s disease.
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