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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

C. Alcohol withdrawal can lead to dehydration due to symptoms such as vomiting, diarrhea, and increased urination. Replacing fluids is important to prevent dehydration and maintain electrolyte balance.
A. Orienting the individual to reality involves helping them understand their current situation and surroundings. While this is an important aspect of nursing care, it may not be the highest priority during the initial phase of alcohol withdrawal.
B. Social support is vital for individuals undergoing alcohol withdrawal, as it can provide emotional reassurance and assistance during a challenging time. However, during the initial phase of withdrawal, the highest priority is typically addressing immediate physiological needs.
D. Restraints should only be used as a last resort and in situations where there is an imminent risk of harm to the individual or others.

A. toys to amuse the children for 3 days. B. their cell phone. C. birth certificates and Social Security cards. D. books and magazines.

Correct Answer is C

Explanation

C. Bringing birth certificates and Social Security cards is essential for establishing identity and accessing necessary services, such as shelters, legal assistance, or government benefits. These documents may be needed for applying for assistance, obtaining housing, or enrolling children in school.
A. Ensuring the well-being and comfort of any children involved is important but bringing toys to amuse them for a few days may not be the highest priority when creating an escape plan from spousal abuse.
B. A cell phone can be used to call for help, contact emergency services, or reach out to trusted individuals for assistance. However, it is not the most important item.
D. Having reading materials may provide distraction and comfort during stressful times but they are not typically considered essential items for an escape plan from spousal abuse.

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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:

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Naxlex Comprehensive Predictor Exams

The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

Correct Answer is C

Explanation

The nurse is assisting a victim of spousal abuse to create a plan for escape if it becomes necessary. The nurse would recommend that the victim bring:

Correct Answer is C

Explanation

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