A nurse is caring client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

Ensure that the client gave informed consent

Administer an oral contrast solution.

Inform the client the procedure will take 60 min.

Ensure that the client's bladder is full.

Answer and Explanation

The Correct Answer is A

A) Ensure that the client gave informed consent: Obtaining informed consent is a critical nursing responsibility prior to any procedure, including an esophagogastroduodenoscopy (EGD). The nurse should verify that the client understands the purpose, risks, and potential outcomes of the procedure. This ensures that the client has voluntarily agreed to undergo the procedure after being fully informed.

B) Administer an oral contrast solution: An esophagogastroduodenoscopy (EGD) does not require the administration of an oral contrast solution. The procedure involves the use of a flexible endoscope to visualize the esophagus, stomach, and duodenum, and is typically performed without contrast agents. Oral contrast is more commonly used in imaging studies such as CT scans or fluoroscopy, not in endoscopy.

C) Inform the client the procedure will take 60 min: The duration of an esophagogastroduodenoscopy typically ranges from 15 to 30 minutes, not 60 minutes. The nurse should inform the client about the usual time frame for the procedure, but stating 60 minutes could be an overestimate. Providing accurate information about the length of the procedure helps manage client expectations.

D) Ensure that the client's bladder is full: The procedure is focused on the upper gastrointestinal tract, so bladder fullness is not necessary for an esophagogastroduodenoscopy. The client should be positioned appropriately, usually in a left lateral position, but there is no need for the bladder to be full. The nurse should ensure that the client follows the pre-procedure guidelines, such as fasting, to reduce the risk of complications.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","F","G","I"]

Explanation

Yellowing of the eyes (Jaundice) → Isoniazid and Rifampin can cause hepatotoxicity, leading to jaundice.

Blurred vision → Ethambutol can cause optic neuritis, leading to blurred vision and color blindness.

Dry eyes (Incorrect) → Not a common side effect of TB medications.

Gastrointestinal:

Abdominal pain → Isoniazid, Rifampin, and Pyrazinamide are hepatotoxic and can cause liver inflammation and gastric irritation.

Weight gain (Incorrect) → TB medications are more likely to cause weight loss rather than gain.

Hematologic:

Increased bruising & bleeding tendencies → Rifampin can cause thrombocytopenia, increasing the risk of bruising and bleeding.

Insomnia (Incorrect) → Not a serious adverse effect of TB medications.

Genitourinary:

Darkening of the urine → Rifampin causes orange-red discoloration of urine, sweat, and tears, which is a benign but expected effect.

Urinary frequency (Incorrect) → Not a known adverse effect of TB medications.

A. Chronic health condition B. Current level of consciousness C. Oxygen saturation level D. Heart rate E. Respiratory rate F. Tremors

Correct Answer is ["B","C","E"]

Explanation

A. Chronic health condition: The client has a history of Parkinson’s disease and anxiety, which are relevant but not immediate concerns. Chronic conditions require long-term management rather than urgent intervention.
B. Current level of consciousness: The client is restless and not following commands, which may indicate hypoxia, worsening infection, or sepsis. A change in mental status is a critical finding requiring immediate evaluation.
C. Oxygen saturation level: The oxygen saturation is 89% on room air, which is below the normal range (≥95%). This suggests respiratory compromise, likely due to pneumonia, requiring urgent oxygen support.
D. Heart rate: The client has a heart rate of 104/min, which is mildly elevated and expected due to fever and respiratory distress. However, it is not the most critical concern compared to respiratory distress and altered mental status.
E. Respiratory rate: The respiratory rate is 30/min, indicating tachypnea and increased work of breathing, suggesting respiratory distress or impending respiratory failure. This requires immediate intervention.
F. Tremors: Tremors are a common finding in Parkinson’s disease and do not require immediate intervention.

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Body system	Findings
Head. Eyes. Ears. Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendancies Insomnia
Genitourinary	Darkening of the urine Urinary frequency

A nurse is caring client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

Nursing Test Bank

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Correct Answer is ["A","B","D","F","G","I"]

Explanation

A nurse is assisting in the care of an older adult client who was admitted Select the 3 findings that require immediate follow-up

Correct Answer is ["B","C","E"]

Explanation

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