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 B

Explanation

B. Children with IDD often require additional support and supervision in performing daily tasks, including personal hygiene routines like handwashing. Depending on the specific needs and abilities of the child, they may require varying levels of assistance and supervision.
A. Communication abilities can vary widely among children with IDD, and many may be able to understand and respond to simple questions or instructions, albeit with some difficulty.
C. Safety scissors are specifically designed for children to use safely, with features such as blunt tips and plastic blades to minimize the risk of injury. Allowing a child with IDD to use safety scissors with adult guidance can promote independence while ensuring safety.
D. Children with IDD often face challenges in following directions and completing tasks independently, particularly those with lower IQ scores.

A. attends a weekly yoga class to improve flexibility and balance. B. gets information about herbal remedies from a health food store employee. C. takes glucosamine daily to prevent knee and hip pain. D. states that prayer helps to improve the knee pain and function.

Correct Answer is B

Explanation

B. It's essential for the client to receive accurate information about their safety, efficacy, and potential interactions with other medications. Health food store employees may not always have the necessary expertise to provide comprehensive information on these aspects.
A. Yoga can indeed improve flexibility and balance, which can be beneficial for individuals with osteoarthritis. Therefore, this choice does not indicate a need for client teaching.
C. Glucosamine helps with pain control and bone remodeling to improve overall functionality.
D. Prayer and spirituality can provide emotional support and improve overall well-being, they may not directly address the underlying physical symptoms of osteoarthritis. This may indicate a need for client teaching, as it may reflect the client's personal beliefs and coping strategies.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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