A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take in preparation for the procedure?
Shave the client from axillae to groin.
Administer a cleansing enema.
Have the client drink contrast medium.
Ensure the signed consent is in the medical record.
The Correct Answer is D
Choice A reason: Shaving the client from axillae to groin is not necessary, as it has no relation to the procedure and can cause skin irritation or infection.
Choice B reason: Administering a cleansing enema is not required, as it does not affect the upper gastrointestinal tract that is examined by the procedure. The client should fast for at least 6 hours before the procedure to ensure an empty stomach.
Choice C reason: Having the client drink contrast medium is not indicated, as it can interfere with the visualization of the mucosa and lesions by the endoscope. The client may receive a local anesthetic spray or gargle to numb the throat and a sedative to relax and reduce discomfort during the procedure.
Choice D reason: Ensuring the signed consent is in the medical record is an essential action, as it indicates that the client has been informed about the purpose, risks, benefits, and alternatives of the procedure and has agreed to undergo it voluntarily.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Hypertension is not a sign of a septic reaction, but rather a sign of a hypertensive or circulatory overload reaction to the blood transfusion.
Choice B reason: Distended neck veins are not a sign of a septic reaction, but rather a sign of a circulatory overload or cardiac failure reaction to the blood transfusion.
Choice C reason: Polyuria is not a sign of a septic reaction, but rather a sign of a hemolytic or renal failure reaction to the blood transfusion.
Choice D reason: Vomiting is a sign of a septic reaction, which occurs when the blood transfusion is contaminated with bacteria. Other signs of a septic reaction include fever, chills, hypotension, and shock.
Correct Answer is D
Explanation
Choice A reason: Prone position is not appropriate for a paracentesis, as it can compress the abdominal organs and make it difficult to access the peritoneal cavity.
Choice B reason: Knees elevated position is not appropriate for a paracentesis, as it can increase the intra-abdominal pressure and reduce the amount of fluid that can be drained.
Choice C reason: Lithotomy position is not appropriate for a paracentesis, as it can expose the genital area and increase the risk of infection or injury.
Choice D reason: Leaning forward position is appropriate for a paracentesis, as it can shift the abdominal organs upward and allow more space for the needle insertion and fluid drainage.
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