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Question

Difficulty: MediumReduction of Risk Potential

A 54-year-old client is being monitored in the recovery unit two hours after an esophagogastroduodenoscopy (EGD) with esophageal dilation. The client suddenly reports severe, sharp pain in the chest and neck area that worsens with swallowing. The nurse notes a heart rate of 122 bpm, a respiratory rate of 26 breaths/min, and a blood pressure of 90/58 mm Hg. Which of the following is the priority nursing action?

  1. Maintain strict NPO status and immediately notify the healthcare provider.Answer
  2. B
    Assist the client into a flat, supine position with the legs elevated.
  3. C
    Auscultate the abdomen starting in the right lower quadrant for bowel sounds.
  4. D
    Administer the prescribed PRN intravenous opioid analgesic for the severe pain.

Answer

Maintain strict NPO status and immediately notify the healthcare provider.
The correct action is to maintain strict NPO status and notify the healthcare provider. The client's symptoms—severe chest and neck pain that worsens with swallowing, tachycardia, tachypnea, and hypotension—are classic indicators of an esophageal perforation. This is a life-threatening complication of esophageal dilation. Keeping the client NPO prevents further leakage of oral or gastric contents into the mediastinum, and the provider must be notified immediately to initiate emergency medical or surgical intervention.

Step-by-Step Solution

1
Analyze the client's new symptoms and vital signs.
The client is exhibiting tachycardia, tachypnea, hypotension, and severe neck and chest pain that worsens with swallowing.
These are significant deviations from a stable post-procedure baseline and indicate a severe complication.
2
Correlate the clinical findings with the specific procedure performed.
An EGD with esophageal dilation carries a risk of esophageal perforation. The symptoms strongly suggest this life-threatening complication, leading to early shock.
Recognizing procedural risks allows the nurse to anticipate and quickly identify complications.
3
Determine the highest priority nursing intervention to mitigate risk.
The client must be kept strictly NPO, and the provider must be notified immediately.
NPO status prevents further leakage of contents into the mediastinum, and the provider is needed for emergency surgical or medical management.

Key Concept

Recognizing and Mitigating Complications of Endoscopic Procedures (Esophageal Perforation)
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Topics

Reduction of Risk Potential

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