A client who is fully awake after a gastroscopy asks the nurse for something to drink.
After confirming that liquids are allowed, which assessment action should the nurse consider a priority before offering oral intake?

Provide thickened fluids with a straw.

Listen to bilateral lung and bowel sounds.

Check the client's Hypoglossal nerve and Vestibulocochlear cranial nerve function.

Check the client's Glossopharyngeal nerve and Vagus cranial nerve function.

Answer and Explanation

The Correct Answer is D

Choice A rationale: Providing thickened fluids with a straw is more related to swallowing difficulties and is not the priority in this context.

Choice B rationale: While assessing lung and bowel sounds is important, it's not directly related to offering oral intake after a gastroscopy.

Choice C rationale: Assessing the Hypoglossal nerve and Vestibulocochlear cranial nerve function isn't directly related to offering oral intake post-gastroscopy.

Choice D rationale: Checking the client's Glossopharyngeal nerve and Vagus cranial nerve function is crucial as these nerves play roles in swallowing, taste, and the gag reflex, which are important before allowing oral intake post-gastroscopy.

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Correct Answer is C

Explanation

Choice A rationale: Peptic ulcer disease doesn't typically present with ecchymosis around the umbilicus (Cullen's sign) or significantly elevated amylase and lipase levels.

Choice B rationale: Gastroenteritis is less likely given the specific symptoms, physical exam findings, and laboratory results indicating pancreatic involvement.

Choice C rationale: Acute pancreatitis fits the clinical picture with epigastric pain after heavy alcohol use, persistent nausea/vomiting, tenderness, and elevated amylase and lipase levels.

Choice D rationale: Diverticulitis typically presents with symptoms more localized to the lower abdomen and doesn't cause the characteristic findings seen in this scenario.

A. a Gloves should be worn during direct contact with the client's skin. B. No precautions in addition to standard precautions are necessary. C. Handwashing is required before and after contact with the client. D. A mask should be worn by anyone entering the client's room.

Correct Answer is A

Explanation

Choice A rationale: Gloves should be worn during direct contact with the client's skin. This is a standard precaution that applies to all clients, but especially to those with infectious diseases that can be transmitted through contact. Secondary syphilis is highly contagious and can be spread through direct contact with the skin lesions or mucous

membranes of an infected person.

Choice B rationale: This is incorrect because secondary syphilis requires more than standard precautions to prevent transmission.

Choice C rationale: This is incorrect because handwashing is a basic component of standard precautions and is not sufficient to prevent the spread of syphilis.

Choice D rationale: This is incorrect because a mask is not necessary for contact precautions, unless the client has respiratory symptoms or is undergoing aerosol- generating procedures.

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A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority before offering oral intake?

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A client who is fully awake after a gastroscopy asks the nurse for something to drink.
After confirming that liquids are allowed, which assessment action should the nurse consider a priority before offering oral intake?