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.
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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Related Questions
Correct Answer is A
Explanation
A) Hot cocoa: Hot cocoa contains the least amount of caffeine compared to the other beverages listed. While it does contain some caffeine, it is significantly lower than coffee, tea, or cola. A typical 8 oz serving of hot cocoa contains approximately 3-10 mg of caffeine, making it the best option for a client looking to reduce caffeine intake.
B) Brewed green tea: Brewed green tea contains more caffeine than hot cocoa. On average, an 8 oz cup of brewed green tea contains about 25-30 mg of caffeine, which is more than cocoa but less than coffee or cola. Although green tea has health benefits, it may not be the best option for those trying to limit caffeine intake.
C) Instant coffee: Instant coffee typically contains more caffeine than brewed green tea or hot cocoa. An 8 oz serving of instant coffee can contain around 30-90 mg of caffeine, depending on the brand and how it is prepared. While it provides a caffeine boost, it is not a good choice for someone seeking to reduce caffeine consumption.
D) Cola soft drink: Cola soft drinks contain a moderate amount of caffeine, usually about 30 mg per 8 oz serving. While this is less than coffee or tea, it still contains more caffeine than hot cocoa and could be a concern for someone trying to cut back on caffeine.
Correct Answer is D
Explanation
A) Rubella titer nonimmune: A nonimmune rubella titer indicates that the client is not immune to rubella, which is a common finding in many pregnant women. However, rubella vaccination is not given during pregnancy because the vaccine is a live virus. The client will typically be vaccinated postpartum. Follow-up would be required, but it is not an urgent concern during the pregnancy itself.
B) Negative varicella titer: A negative varicella titer means the client is not immune to chickenpox, which is a concern because varicella can cause serious complications during pregnancy. However, similar to rubella, the varicella vaccine is contraindicated during pregnancy, and vaccination would be given postpartum. This requires follow-up after delivery but does not require urgent intervention during the pregnancy.
C) Positive Rh factor: The Rh factor is a blood type characteristic, but what is typically more concerning is the Rh incompatibility, which occurs when a Rh-negative mother carries a Rh-positive baby. A positive Rh factor is not a problem for the client themselves but could be important if the father is Rh-positive. If there is concern for Rh incompatibility, the nurse would monitor for the development of Rh sensitization and administer Rh immunoglobulin (RhoGAM) if needed. This does not require urgent intervention unless Rh incompatibility is confirmed.
D) Positive serologic test for syphilis: A positive test for syphilis requires immediate follow-up intervention. Syphilis is a sexually transmitted infection that can cause serious complications during pregnancy, including miscarriage, stillbirth, preterm birth, and congenital syphilis. Treatment with penicillin is recommended to prevent transmission to the baby and to treat the infection in the mother. A positive serologic test for syphilis warrants prompt intervention.
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