A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take in preparation for the procedure?
Shave the client from axillae to groin.
Administer a cleansing enema.
Have the client drink contrast medium.
Ensure the signed consent is in the medical record.
The Correct Answer is D
Choice A reason: Shaving the client from axillae to groin is not necessary, as it has no relation to the procedure and can cause skin irritation or infection.
Choice B reason: Administering a cleansing enema is not required, as it does not affect the upper gastrointestinal tract that is examined by the procedure. The client should fast for at least 6 hours before the procedure to ensure an empty stomach.
Choice C reason: Having the client drink contrast medium is not indicated, as it can interfere with the visualization of the mucosa and lesions by the endoscope. The client may receive a local anesthetic spray or gargle to numb the throat and a sedative to relax and reduce discomfort during the procedure.
Choice D reason: Ensuring the signed consent is in the medical record is an essential action, as it indicates that the client has been informed about the purpose, risks, benefits, and alternatives of the procedure and has agreed to undergo it voluntarily.
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Related Questions
Correct Answer is B
Explanation
Choice A: This is incorrect because maintaining the client on bed rest can increase the risk of complications such as pneumonia, thromboembolism, or pressure ulcers. The nurse should encourage early ambulation and frequent position changes to promote healing and prevent complications.
Choice B: This is correct because repositioning the client can help relieve pressure and discomfort from the incision site. The nurse should assist the client to change positions every 2 hours and use pillows or splints to support the incision.
Choice C: This is incorrect because applying a warm, moist compress to the incision area can interfere with wound healing and increase the risk of infection. The nurse should keep the incision site clean and dry and follow the provider's orders for dressing changes.
Choice D: This is incorrect because administering an additional dose of pain medication is not necessary when the client reports a pain level of 2 on a scale of 0 to 10. The nurse should monitor the client's pain level and administer pain medication as prescribed and as needed.
Correct Answer is A
Explanation
Choice A reason: Difficulty swallowing is a sign of anaphylaxis, which is a severe allergic reaction that can cause swelling of the throat and tongue, leading to airway obstruction and respiratory distress.
Choice B reason: Petechial rash on the abdomen is not a sign of anaphylaxis, but rather a sign of thrombocytopenia, which is a low platelet count that can cause bleeding under the skin.
Choice C reason: Hypertension is not a sign of anaphylaxis, but rather a sign of high blood pressure, which can be caused by various factors such as stress, pain, or kidney disease.
Choice D reason: Bilateral tinnitus is not a sign of anaphylaxis, but rather a sign of hearing loss or damage, which can be caused by exposure to loud noise, ear infection, or medication side effects.
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