The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment?
Thirst
Sore throat
Abdominal distention
Drowsiness
The Correct Answer is C
Choice A Reason:
Thirst is a common and expected symptom after an EGD, especially if the client has been fasting before the procedure. It does not typically indicate a complication and can be managed by gradually reintroducing fluids as tolerated. Therefore, thirst does not require further nursing assessment beyond routine post-procedure care.
Choice B Reason:
A sore throat is also a common symptom following an EGD. The procedure involves passing an endoscope through the throat, which can cause temporary irritation and discomfort. This symptom usually resolves on its own within a few days and does not indicate a serious complication. Therefore, a sore throat does not require further nursing assessment beyond providing comfort measures such as lozenges or warm saltwater gargles.
Choice C Reason:
Abdominal distention is a concerning symptom that requires further nursing assessment. It can indicate complications such as perforation, bleeding, or infection following the EGD. Perforation of the gastrointestinal tract is a rare but serious complication that can lead to peritonitis and sepsis if not promptly addressed. Therefore, any signs of abdominal distention should be reported to the provider immediately for further evaluation and intervention.
Choice D Reason:
Drowsiness is a common side effect of the sedatives used during the EGD procedure. It is expected that the client may feel drowsy or sleepy for a few hours after the procedure as the sedative wears off. This symptom does not typically require further nursing assessment unless it persists for an unusually long time or is accompanied by other concerning symptoms such as difficulty breathing or altered mental status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: No change to the heparin rate is not appropriate in this scenario. The normal range for PTT is generally between 25 to 35 seconds. However, for a client on heparin therapy, the target PTT is typically 1.5 to 2.5 times the normal range, which would be approximately 60 to 80 seconds. Since the client’s PTT is only 25 seconds, it indicates that the blood is clotting too quickly, and the heparin dose is insufficient.
Choice B reason: Decreasing the heparin rate would further reduce the anticoagulant effect, which is not advisable given the current PTT of 25 seconds. Lowering the heparin rate could increase the risk of thrombus formation and worsen the deep vein thrombosis (DVT) condition.
Choice C reason: Stopping heparin and starting warfarin is not an immediate solution. Warfarin takes several days to achieve its full anticoagulant effect, and during this transition period, the client would be at risk of clot formation. Heparin provides immediate anticoagulation, which is crucial in the acute management of DVT.
Choice D reason: Increasing the heparin rate is the correct action. The current PTT of 25 seconds is below the therapeutic range for a client on heparin therapy. Increasing the heparin rate will help achieve the desired anticoagulant effect, prolonging the PTT to the target range of 60 to 80 seconds.
Correct Answer is A
Explanation
Choice A Reason:
Hemoptysis, or coughing up blood, is a common feature of both mitral valve stenosis and mitral valve regurgitation. In mitral valve stenosis, the narrowing of the valve leads to increased pressure in the pulmonary veins, which can cause pulmonary congestion and hemoptysis. Similarly, in mitral valve regurgitation, the backflow of blood into the left atrium increases pulmonary pressure, potentially leading to pulmonary edema and hemoptysis. Therefore, hemoptysis is a shared symptom of both conditions.
Choice B Reason:
A high-pitched holosystolic murmur is more commonly associated with mitral valve regurgitation rather than mitral valve stenosis. In mitral valve regurgitation, the murmur is caused by the backflow of blood from the left ventricle into the left atrium during systole3. Mitral valve stenosis, on the other hand, typically presents with a diastolic murmur due to the turbulent flow of blood through the narrowed valve during diastole. Therefore, a high-pitched holosystolic murmur is not a common feature of both disorders.
Choice C Reason:
Hepatomegaly, or an enlarged liver, can occur in advanced cases of both mitral valve stenosis and mitral valve regurgitation due to right-sided heart failure. However, it is not a primary or common feature of these conditions. Hepatomegaly is more often associated with conditions that directly affect the right side of the heart or cause systemic congestion. Therefore, hepatomegaly is not a common feature of both mitral valve stenosis and mitral valve regurgitation.
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