A client suspected of having a duodenal ulcer has undergone esophagogastroduodenoscopy. The nurse would place the highest priority on which item as part of the client’s care plan?

Monitoring the temperature.

Monitoring complaints of heartburn.

Giving warm gargles for a sore throat.

Assessing for the return of the gag reflex.

Answer and Explanation

The Correct Answer is D

Choice A reason: Monitoring temperature detects infection but is less urgent than ensuring airway safety post-endoscopy. Gag reflex assessment prevents aspiration, making this incorrect, as it’s secondary to the nurse’s priority of confirming safe swallowing after the procedure.

Choice B reason: Heartburn monitoring is relevant for ulcers but not the immediate post-endoscopy priority. Gag reflex return is critical, making this incorrect, as it’s less urgent than the nurse’s focus on airway protection after esophagogastroduodenoscopy in the client.

Choice C reason: Warm gargles soothe a sore throat but don’t address the risk of aspiration post-endoscopy. Assessing gag reflex is vital, making this incorrect, as it’s not the highest priority compared to the nurse’s focus on ensuring airway safety.

Choice D reason: Assessing the return of the gag reflex post-esophagogastroduodenoscopy is the highest priority to prevent aspiration due to sedation. This aligns with post-procedure safety, making it the correct item for the nurse to prioritize in the client’s care plan.

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Correct Answer is B

Explanation

Choice A reason: Unprotected sex is a risk for hepatitis B or C, not A, which is fecal-oral. Shellfish consumption is a common source, making this incorrect, as it doesn’t support the nurse’s diagnosis of hepatitis A based on the client’s history.

Choice B reason: Eating contaminated shellfish is a common cause of hepatitis A, transmitted via the fecal-oral route, with symptoms appearing 2-6 weeks later. This aligns with the diagnosis, making it the correct statement supporting the client’s hepatitis A diagnosis.

Choice C reason: Sharing needles spreads hepatitis B or C, not A, which is foodborne. Shellfish is a hepatitis A source, making this incorrect, as it’s unrelated to the nurse’s evaluation of the client’s flu-like symptoms and jaundice.

Choice D reason: Blood transfusions before 1992 risked hepatitis C, not A, which is fecal-oral. Eating shellfish supports hepatitis A, making this incorrect, as it doesn’t align with the nurse’s diagnosis based on the client’s jaundice and flu-like symptoms.

A. A 45-year-old with a nasogastric (NG) tube who has dry oral mucosa and reports feeling very thirsty. B. A 57-year-old receiving IV diuretics whose blood pressure is 88/52 mm Hg. C. A 67-year-old with nausea and vomiting who reports abdominal cramps. D. A 77-year-old with normal saline infusing at 150 mL/hr with an average hourly urine output.

Correct Answer is B

Explanation

Choice A reason: Dry mucosa and thirst suggest dehydration, but hypotension (88/52) is more life-threatening. Low blood pressure requires immediate assessment, making this incorrect, as it’s less urgent than the nurse’s priority to address the client with critical hemodynamic instability.

Choice B reason: A blood pressure of 88/52 mm Hg in a client on IV diuretics indicates severe hypotension, a life-threatening condition requiring immediate assessment. This aligns with prioritization in acute care, making it the correct client for the nurse to assess first post-shift report.

Choice C reason: Nausea, vomiting, and cramps are concerning but less urgent than hypotension (88/52), which risks organ perfusion. Low blood pressure is critical, making this incorrect, as it’s secondary to the nurse’s priority of assessing the client with unstable vitals.

Choice D reason: Normal saline at 150 mL/hr with adequate urine output is stable. Hypotension (88/52) is more critical, making this incorrect, as it’s a lower priority compared to the nurse’s need to assess the client with life-threatening low blood pressure first.

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A client suspected of having a duodenal ulcer has undergone esophagogastroduodenoscopy. The nurse would place the highest priority on which item as part of the client’s care plan?

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