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Difficulty: HardReduction of Risk Potential

A client is transferred to the medical-surgical unit after undergoing an esophagogastroduodenoscopy (EGD) with a gastric biopsy under conscious sedation. Which of the following nursing actions and assessments should the nurse implement to reduce the risk of postoperative complications? Select all that apply.

  1. Withhold all oral fluids and medications until the client demonstrates a return of the gag and swallow reflexes.Answer
  2. B
    Position the client flat and supine for 2 hours post-procedure to promote comfort and reduce the risk of orthostatic hypotension.
  3. C
    Delegate the initial post-procedure vital sign measurements and focused respiratory assessment to the unlicensed assistive personnel (UAP).
  4. Assess the client for new-onset, severe abdominal, chest, or neck pain with accompanying abdominal rigidity.Answer
  5. E
    Interpret an arterial blood gas (ABG) result of pH 7.26, PaCO2 58 mm Hg, and HCO3 24 mEq/L as fully compensated respiratory acidosis requiring no immediate intervention.
  6. F
    Continue routine monitoring without notifying the healthcare provider if the client develops a narrowing pulse pressure and mild tachycardia, provided the systolic blood pressure remains above 100 mm Hg.

Answer

The nurse must withhold all oral intake until the gag reflex returns to prevent aspiration, and must assess for severe abdominal, chest, or neck pain which indicates a potential gastrointestinal perforation.
The correct actions focus on mitigating the highest priority risks post-EGD. Local anesthetics suppress the gag reflex, making aspiration a severe risk until the reflex fully returns. Additionally, a gastric biopsy can cause a tear or perforation in the gastrointestinal tract, which classically presents with severe, sudden-onset abdominal, chest, or neck pain alongside abdominal rigidity.

Step-by-Step Solution

1
Analyze the procedure and the client's current status.
The client had an EGD with gastric biopsy under conscious sedation. The primary risks include aspiration, respiratory depression, hemorrhage, and viscus perforation.
Identifying potential procedure-specific complications guides the required nursing assessments and interventions.
2
Evaluate the correct options against known risks.
Withholding oral intake mitigates the risk of aspiration due to lingering local anesthesia. Assessing for severe pain and rigidity directly monitors for gastrointestinal perforation.
These actions directly address the most life-threatening complications of an EGD.
3
Critique the remaining options for safety and physiological accuracy.
Flat positioning increases aspiration risk. Initial assessments cannot be delegated. Narrowing pulse pressure is an early sign of shock requiring immediate reporting. The provided ABG demonstrates uncompensated respiratory acidosis, a medical emergency.
Eliminating incorrect actions ensures adherence to safe delegation, accurate clinical interpretation, and early recognition of physiological deterioration.

Key Concept

Post-procedure care following endoscopy focuses on maintaining airway patency, preventing aspiration, and detecting early signs of severe complications such as perforation, hemorrhage, and over-sedation.
Estimated Time:2m 0s
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Reduction of Risk Potential

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