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. Sodium intake can influence lithium excretion and affect serum lithium levels. Maintaining a consistent and adequate sodium intake is important for stabilizing serum lithium levels and optimizing the medication's therapeutic effects.
A. Patients should have their serum lithium levels checked regularly, typically every 3 months, not just every 6 months as suggested.
B. Clients should never adjust their lithium dose without consulting their healthcare provider. Lithium dosage adjustments should be made only under the guidance and supervision of a healthcare professional based on the client's clinical response, serum lithium levels, and overall treatment plan.
D. Adequate hydration is essential for overall health and well-being, and dehydration can increase the risk of lithium toxicity.

A. Assess breath sounds B. Monitor serum protein levels C. Assess peripheral pulses D. Monitor daily weights

Correct Answer is D

Explanation

D. Furosemide is a diuretic that works by increasing urine output, which in turn reduces fluid retention and swelling. By tracking the client's weight on a daily basis, the nurse can obtain a clear and consistent measure of how much fluid is being lost as a result of the medication.
A. Monitoring respiratory status but it may not be the most direct method for evaluating the effectiveness of furosemide in reducing peripheral edema.
B. Monitoring serum protein levels may provide information about the client's nutritional status and liver function, but it is not typically used as a direct measure of response to furosemide for peripheral edema.
C. Improvement in peripheral pulses may indicate a reduction in fluid overload and resolution of edema. However, changes in peripheral pulses may be influenced by factors other than diuresis, such as vascular disease or cardiac function.

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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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Explanation

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Correct Answer is D

Explanation

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