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 D
Explanation
“I should expect less than 25 mL of secretions per day in the drainage devices.” After a mastectomy with breast reconstruction using a tissue expander, you may go home with drains in your chest to remove extra fluid.
Choice A is wrong because performing strength-building arm exercises using a 15-pound weight is not recommended.
Choice B is wrong because waiting 2 months before additional saline can be added to the breast expander is not accurate.
Choice C is wrong because keeping the left arm flexed at the elbow as much as possible is not recommended.
Correct Answer is D
Explanation
A pneumothorax is a collapsed lung that occurs when air leaks into the space between the lung and the chest wall.
This can cause diminished breath sounds on the affected side. Distended neck veins are not a symptom of pneumothorax.
B) Itching over the incision is not a symptom of pneumothorax.
C) Irregular heart rate is not a symptom of pneumothorax.
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