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 A

Explanation

Choice A reason: Limiting dietary fiber is incorrect for IBS, as soluble fiber helps regulate bowel movements. This indicates a need for further teaching, making it the correct statement, as it contradicts the nurse’s instructions to include fiber for IBS symptom management.

Choice B reason: Drinking 8 to 10 cups of fluid daily supports hydration and bowel function in IBS, showing understanding. This is incorrect, as it aligns with the nurse’s teaching, unlike the fiber limitation statement requiring further client education.

Choice C reason: Eating regular meals and chewing well stabilizes digestion in IBS, reflecting correct understanding. This is incorrect, as it aligns with the nurse’s instructions, unlike the fiber limitation statement that indicates a need for further teaching.

Choice D reason: Taking prescribed medications to regulate bowel patterns is appropriate for IBS management, showing understanding. This is incorrect, as it aligns with the nurse’s teaching, unlike the incorrect fiber limitation statement needing further client instruction.

A. Apply supplemental oxygen via nasal cannula. B. Administer intravenous morphine for pain. C. Keep the hard collar in place until cleared. D. Administer intravenous methylprednisolone (Solu-Medrol) as prescribed.

Correct Answer is C

Explanation

Choice A reason: Supplemental oxygen is unnecessary with a normal respiratory rate (16) and stable vitals. Maintaining the collar prevents spinal injury, making this incorrect, as it’s not indicated compared to the nurse’s priority of ensuring spinal stability in a client with a fall history.

Choice B reason: Morphine for pain is premature without confirming spinal stability, as it may mask symptoms. Keeping the collar in place is critical, making this incorrect, as it risks missing neurological changes in the nurse’s care of a potential spinal injury client.

Choice C reason: Keeping the hard collar in place until cleared by imaging prevents worsening of potential spinal injury after a trampoline fall. This aligns with trauma care protocols, making it the correct action for the nurse to take to ensure the client’s safety and stability.

Choice D reason: Methylprednisolone is used for confirmed spinal cord injury, not suspected cases without imaging. Maintaining the collar is the priority, making this incorrect, as it’s premature compared to the nurse’s focus on spinal precautions in a client with numbness and tingling.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse provides instructions to a client about measures to treat irritable bowel syndrome (IBS). Which statement by the client indicates a need for further teaching?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?

The nurse is providing dietary education to a client with gastroesophageal reflux disease (GERD). The nurse indicates that the client understands the teaching if the client states a plan to avoid which foods to prevent symptom exacerbation? (Select all that apply)

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?

The nurse is reviewing a client’s record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?

A client is brought to the emergency department with partial-thickness burns to the face, neck, arms, and chest after trying to put out a car fire. The nurse needs to implement which nursing actions for this client? (Select all that apply)

A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?