Examkin

Question

Difficulty: MediumReduction of Risk Potential

A 62-year-old client is transferred to the medical-surgical unit after undergoing an esophagogastroduodenoscopy (EGD) with gastric biopsies. Which of the following assessment findings or situations require immediate intervention by the nurse? Select all that apply.

  1. A resting heart rate of 114 beats/min accompanied by a narrowing pulse pressureAnswer
  2. The client's abdomen feels rigid and board-like during light palpationAnswer
  3. C
    The client is positioned in a lateral side-lying posture while the gag reflex remains absent
  4. The client develops a sudden temperature elevation to 101.5°F (38.6°C)Answer
  5. E
    The client experiences frequent belching and reports a sensation of abdominal fullness
  6. F
    An absent gag reflex is noted 30 minutes after the completion of the procedure

Answer

The findings requiring immediate intervention are a resting heart rate of 114 beats/min with a narrowing pulse pressure, a rigid and board-like abdomen, and a sudden temperature elevation.
Following an EGD with biopsies, the nurse must monitor for severe complications such as hemorrhage and perforation. A narrowing pulse pressure combined with tachycardia indicates early hypovolemic shock resulting from internal bleeding. A rigid, board-like abdomen and a sudden fever are classic indicators of visceral perforation and resulting peritonitis. These three findings are life-threatening and require immediate medical intervention.

Step-by-Step Solution

1
Analyze the procedure and its associated risks.
An EGD with biopsies carries primary risks of gastrointestinal hemorrhage, visceral perforation, and aspiration.
Understanding the risks directs the focused post-operative physical assessment.
2
Evaluate the hemodynamic and systemic assessment findings.
Tachycardia with a narrowing pulse pressure suggests early shock (bleeding). A rigid abdomen and sudden fever suggest peritonitis (perforation).
These are life-threatening physiological complications requiring emergency medical management.
3
Evaluate the remaining options for expected post-procedure status.
Belching, an absent gag reflex at 30 minutes, and lateral positioning are all normal or therapeutic aspects of post-EGD care.
Recognizing expected findings prevents unnecessary interventions and focuses attention on true instability.

Key Concept

Reduction of Risk Potential: Post-Endoscopy Complications
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic