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 B
Explanation
B. Individuals with borderline personality disorder may exhibit behavior that generates conflict among staff members or within their interpersonal relationships. They may have difficulty regulating emotions, experience intense mood swings, and engage in impulsive or manipulative behaviors that contribute to conflicts with others.
A. Individuals with borderline personality disorder often struggle with interpersonal relationships and may have difficulty maintaining stable and healthy connections with others.
C. Suspiciousness of others is not a primary characteristic of borderline personality disorder.
D. Bizarre speech patterns are not typically associated with borderline personality disorder.
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.
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