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

Answer and Explanation

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

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Correct Answer is A

Explanation

Choice A rationale
Jaundice, a common symptom of cholecystitis, is a yellow discoloration of the skin and whites of the eyes (sclera) caused by an excess of bilirubin in the blood. The sclera is often the first place where jaundice is noticeable because the high amount of elastin in the sclera binds to bilirubin, causing a yellowish discoloration.
Choice B rationale
While nail beds can sometimes show signs of certain health issues, they are not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.
Choice C rationale
The periumbilical area (around the belly button) is not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.
Choice D rationale

The webbed areas of the fingers are not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.

A. Clear liquid diet. B. Nasogastric tube insertion. C. Intravenous antibiotics. D. Strict intake and output monitoring.

Correct Answer is A

Explanation

Choice A rationale
A clear liquid diet may not provide adequate nutrition for a patient with peritonitis. Peritonitis, an inflammation of the peritoneum, can be caused by infection, including from bacteria or fungi, or by a rupture in the abdomen. It’s a serious condition that requires immediate treatment, often including antibiotics and surgery.
Choice B rationale
Nasogastric tube insertion can be a part of the management for peritonitis. It can help decompress the stomach and relieve symptoms such as nausea and vomiting.
Choice C rationale
Intravenous antibiotics are typically a part of the treatment plan for peritonitis, as the condition is often caused by an infection.
Choice D rationale
Strict intake and output monitoring is important in the management of peritonitis. It helps assess the patient’s fluid balance and response to treatment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a patient who is African American and has cholecystitis. Which of the following areas should the nurse inspect to monitor for the presence of jaundice?

Correct Answer is A

Explanation

The nurse is reviewing the medical record of a patient with peritonitis. Which prescription should prompt the nurse to seek clarification from the gastroenterologist?

Correct Answer is A

Explanation

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