A nurse is assisting with the plan of care for a client who had an upper endoscopy 1 hr ago. The nurse should place the priority on monitoring which of the following?
Sore throat
Abdominal bloating
Gag reflex
Belching
The Correct Answer is C
Choice A rationale
While a sore throat can be a side effect of an upper endoscopy, it is not the priority for monitoring after the procedure.
Choice B rationale
Abdominal bloating can occur after an upper endoscopy, but it is not the priority for monitoring.
Choice C rationale
Monitoring the return of the gag reflex is a priority after an upper endoscopy. The gag reflex may be impaired due to the use of local anesthetics during the procedure. An impaired gag reflex increases the risk of aspiration.
Choice D rationale
Belching can occur after an upper endoscopy, but it is not the priority for monitoring
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
After a Roux-en-Y surgical procedure, patients are typically put on a liquid-only diet for the first week or two after surgery. Over the next month, they are able to add soft food and eventually regular food back into their diet. Given that the patient is only one day postoperative, the consumption of solid foods like strawberry yogurt could potentially lead to
complications such as dumping syndrome, which is a group of symptoms that includes vomiting, nausea, and dizziness. It occurs when food moves from your stomach into your small intestine too quickly.
Choice B rationale
Chicken broth is a clear liquid and is generally considered safe for a patient who is one day postoperative from a Roux-en-Y surgical procedure. It is easily digestible and does not put undue stress on the digestive system.
Choice C rationale
Apple juice is a clear liquid and is generally considered safe for a patient who is one day postoperative from a Roux-en-Y surgical procedure. It is easily digestible and does not put undue stress on the digestive system.
Choice D rationale
Iced tea is a clear liquid and is generally considered safe for a patient who is one day postoperative from a Roux-en-Y surgical procedure. It is easily digestible and does not put undue stress on the digestive system.
Correct Answer is C
Explanation
Choice A rationale
Monitoring peripheral pulses every 8 hours is not typically a priority in the care plan for a patient with acute pancreatitis. While cardiovascular monitoring is important in all patients, it is not specifically related to the management of acute pancreatitis.
Choice B rationale
Measuring urine output every 4 hours can be important in assessing fluid balance and kidney function, but it is not the primary intervention in the care plan for a patient with acute pancreatitis.
Choice C rationale
Maintaining NPO (nothing by mouth) status is a key intervention in the management of acute pancreatitis. This helps to rest the pancreas and reduce the production of digestive enzymes.
Choice D rationale
Ambulating the patient three times daily is generally a good practice for postoperative recovery, but it is not specific to the care of a patient with acute pancreatitis. In the acute phase of pancreatitis, rest is often recommended.
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