Examkin

Question

Difficulty: HardBasic Care and Comfort

A practical nurse is providing basic care for a client who returned to the medical unit 2 hours ago following an esophagogastroduodenoscopy (EGD) performed with a topical anesthetic throat spray. The client reports feeling hungry, and their family has brought a culturally specific, home-cooked meal. Which of the following actions should the nurse take first?

  1. Verify the return of the client's gag reflex before permitting the consumption of any food or liquids.Answer
  2. B
    Assist the client into a supine position in bed to promote abdominal relaxation while they eat the meal.
  3. C
    Prioritize arranging the meal tray and documenting the family's cultural food preferences in the medical record.
  4. D
    Withhold the culturally specific food and instead serve the hospital's standard post-procedure clear liquid diet.

Answer

The nurse must verify the return of the client's gag reflex before allowing any oral intake to prevent aspiration.
Following an EGD with topical throat anesthesia, the client's gag and swallow reflexes are temporarily suppressed. The absolute priority action in basic care is to ensure airway safety by verifying that the gag reflex has fully returned before allowing the client to consume any food or liquids, thereby preventing aspiration.

Step-by-Step Solution

1
Analyze the client's recent procedure and its physiological effects.
The client received a topical anesthetic throat spray for an EGD.
Local anesthesia to the throat impairs the gag and swallow reflexes, creating a temporary but high risk for aspiration.
2
Evaluate the requested intervention (eating a meal).
The client wants to eat a solid meal brought by the family.
Introducing oral intake before protective airway reflexes have returned can lead to choking or aspiration pneumonia.
3
Determine the priority nursing action based on ABCs (Airway, Breathing, Circulation).
Airway protection is the absolute highest priority.
The nurse must formally assess the return of the gag reflex before permitting any food or liquids, regardless of cultural preferences or the client's current hunger.

Key Concept

Airway protection and aspiration precautions during basic care and feeding
Estimated Time:1m 15s
Rate this question

Topics

Basic Care and Comfort

More questions from this topic