The nurse is caring for a client after an endoscopy. The client is lethargic and not responding to verbal commands. The priority nursing action is to:
assess the client's airway and breathing.
assess the client's gag reflex.
call the physician immediately.
document this as normal findings and reassess in half an hour.
The Correct Answer is A
A. The client's lethargy and lack of response to verbal commands raise concerns about their level of consciousness and potential airway compromise. Assessing the client's airway and breathing involves ensuring that the airway is clear, assessing respiratory rate and effort, and monitoring oxygenation.
B. Assessing the gag reflex can provide additional information about airway protection. However, it should not delay assessment and intervention for airway and breathing concerns.
C. Contacting the physician may be necessary but it is not the priority nursing action in this situation. The nurse should first assess the client's airway and breathing to ensure their safety and stability.
D. The client's lethargy and unresponsiveness are not normal findings after an endoscopy and require immediate assessment and intervention. Delaying assessment and intervention could lead to serious complications, including respiratory compromise or airway obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The client's lethargy and lack of response to verbal commands raise concerns about their level of consciousness and potential airway compromise. Assessing the client's airway and breathing involves ensuring that the airway is clear, assessing respiratory rate and effort, and monitoring oxygenation.
B. Assessing the gag reflex can provide additional information about airway protection. However, it should not delay assessment and intervention for airway and breathing concerns.
C. Contacting the physician may be necessary but it is not the priority nursing action in this situation. The nurse should first assess the client's airway and breathing to ensure their safety and stability.
D. The client's lethargy and unresponsiveness are not normal findings after an endoscopy and require immediate assessment and intervention. Delaying assessment and intervention could lead to serious complications, including respiratory compromise or airway obstruction.
Correct Answer is ["A","B","C"]
Explanation
A. herbal products are not subject to the same rigorous standards of quality, purity, and consistency. Therefore, it is essential for individuals to purchase herbal products from reputable manufacturers that adhere to good manufacturing practices and quality control measures to ensure product safety and efficacy.
B. Herbal products can interact with prescription medications, over-the-counter drugs, or other supplements, leading to potential adverse effects or reduced efficacy of treatment.
C. Like pharmaceutical drugs, herbal therapies can have side effects, interactions, and contraindications. Some herbs may cause adverse reactions, allergic responses, or interactions with medications, leading to potentially serious consequences.
D. Many cultures have used herbs for centuries for various health benefits, and research continues to explore the potential therapeutic effects of herbal remedies.
E. It is important to note that not all herbs are inherently harmful. Many herbs used in traditional medicine systems and herbal therapies have a long history of safe use when used appropriately and in recommended doses.
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