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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Acupuncture is based on the concept of Qi (pronounced "chee"), or vital energy, flowing along specific pathways or meridians in the body. The insertion of needles at specific points along these meridians is believed to regulate the flow of Qi, restoring balance and promoting healing.
A. Acupuncture primarily involves the insertion of thin needles into specific points on the body to stimulate nerve-rich areas, not the manipulation of the spinal column.
B. Acupuncture does not involve the ingestion of substances, but rather the insertion of needles into specific points on the body to stimulate energy flow.
C. Herbal remedies may be used in conjunction with acupuncture in traditional Chinese medicine but acupuncture itself does not involve the ingestion of substances.
Correct Answer is B
Explanation
B. Naloxone administration can rapidly reverse the effects of opioids, potentially leading to the rapid onset of opioid withdrawal symptoms, which may include respiratory depression. Therefore, close monitoring of the client's airway, respiratory rate, oxygen saturation, blood pressure, and heart rate is critical to ensure their safety and stability.
A. Assessing and managing the client's gastrointestinal status may be necessary depending on the clinical situation but it is not the most urgent concern immediately following naloxone administration.
C. Assessing urinary output and ensuring adequate fluid balance is important. However, it is not the highest priority immediately after naloxone administration.
D. Hyperpyrexia, or extremely high fever, is not a common immediate concern following naloxone administration.
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