A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure.
Which of the following assessments is the nurse's priority?
Level of consciousness
Gag reflex
Nausea
Pain
The Correct Answer is B
Choice A reason:
While assessing the client's level of consciousness is important, it is not the priority after an EGD procedure. Ensuring the client's airway and protective reflexes is more crucial.
Choice B reason:
This is the correct answer. After an EGD, the client may have residual effects from sedation. Assessing the gag reflex helps ensure that the client's airway is protected.
Choice C reason:
Nausea is a common side effect after an EGD, but it is not the priority assessment. Ensuring the client's airway and safety come first.
Choice D reason:
Assessing pain is important for the client's comfort, but it is not the priority assessment after an EGD. Ensuring the client's airway and protective reflexes is more crucial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Avoiding chemicals that are toxic to the liver is a valid recommendation for liver health, but it is not specific to preventing hepatitis E virus infection.
Choice B reason:
Limiting alcohol intake is an important measure for maintaining liver health, but it is not a specific prevention measure for hepatitis E virus.
Choice C reason:
Wearing a condom during sexual contact is an important measure to prevent the transmission of certain sexually transmitted infections (STIs), but hepatitis E is primarily transmitted through contaminated water and not through sexual contact.
Choice D reason:
Following proper hand-washing techniques is a crucial preventive measure for hepatitis E virus. This virus is primarily transmitted through the fecal-oral route, often via contaminated water or food. Proper hand hygiene can significantly reduce the risk of transmission.
Correct Answer is A
Explanation
Choice A reason:
A painless sore with raised edges is a characteristic early sign of oral cancer. It may appear as a small, painless lump or sore in the mouth, often with raised edges. This finding should raise suspicion and prompt further evaluation.
Choice B reason:
Diffuse inflammation of the buccal mucosa is a non-specific finding and can be caused by various factors, including infection or irritation. While it's important to assess the oral mucosa for any abnormalities, it is not specific to oral cancer.
Choice C reason:
Dull pain radiating to the ears and teeth is not a characteristic early sign of oral cancer. Pain associated with oral cancer may occur in later stages or if there is local invasion of nerves.
Choice D reason:
Areas of tenderness that make chewing difficult may occur for various reasons, including dental issues or other oral health problems. While this can be distressing for the patient, it is not specific to oral cancer.
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