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. This statement demonstrates progress and indicates that the client is beginning to take responsibility off themselves for the sexual assault. Acknowledging that the assault was not their fault is a crucial step in healing from trauma. It shows an acceptance of reality and a shift away from self-blame or feelings of guilt.
A. It may indicate that the client is still struggling to acknowledge the true nature of the assault and may not have fully processed their feelings and experiences related to the trauma.
C. This statement may suggest avoidance or attempts to control future situations to prevent similar experiences. While seeking support and safety measures can be beneficial, solely relying on external factors such as double dates to prevent sexual assault may not address underlying issues or promote healing from the trauma.
D. It suggests a continuation of internalized victim-blaming beliefs and may indicate that the client has not fully shifted away from feelings of guilt or responsibility for the assault.

A. must perform other psychomotor tests to determine intoxication. B. is legally intoxicated. C. would be considered intoxicated depending on state law requirements. D. has a BAL within legal limits.

Correct Answer is B

Explanation

B. In the United States, the legal limit for blood alcohol concentration (BAC) is 0.08%. A BAC of 0.11 g/dL exceeds this limit, indicating that the client is indeed legally intoxicated.
A. Psychomotor tests, such as field sobriety tests, may be performed to assess the client's level of impairment and determine if they are intoxicated when the BAL is below threshold for intoxication.
C. State laws do not vary in this regard for the legal limit of BAC for driving; however, penalties and specific charges can vary from state to state.
D. A blood alcohol level (BAL) of 0.11 g/dL is above the legal limit for driving in many jurisdictions, where the legal limit is typically set at 0.08 g/dL.

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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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