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Difficulty: MediumReduction of Risk Potential

A 55-year-old client returns to the medical-surgical unit following an esophagogastroduodenoscopy (EGD) with banding of esophageal varices. The client received intravenous midazolam and fentanyl during the procedure and is currently lethargic but arousable. The client's vital signs are: BP 110/70 mmHg, HR 85 bpm, RR 14/min, and SpO2 96% on room air. Which of the following actions is the most appropriate priority for the nurse to reduce the client's risk of physiological complications?

  1. Maintain the client strictly NPO until the return of the gag reflex is clinically confirmed.Answer
  2. B
    Place the client in a flat, supine position to promote peripheral circulation and hemodynamic stability.
  3. C
    Palpate the client's abdomen deeply for signs of visceral bleeding before auscultating for bowel sounds.
  4. D
    Prepare to draw an arterial blood gas (ABG) sample to evaluate for metabolic alkalosis caused by the sedation.

Answer

The correct action is to maintain the client strictly NPO until the return of the gag reflex is clinically confirmed.
Following an upper endoscopy (EGD), the client's throat is numbed with a topical anesthetic, temporarily abolishing the gag reflex. Combined with the lingering effects of procedural sedation, the client is at a high risk for aspiration. The nurse must withhold all oral fluids and food (NPO) until the gag reflex has demonstrably returned.

Step-by-Step Solution

1
Analyze the procedure and medications administered.
The client underwent an EGD with variceal banding and received conscious sedation (midazolam, fentanyl) along with a topical anesthetic spray to the posterior pharynx.
Understanding the procedural interventions helps identify the most immediate physiological risks.
2
Identify the greatest physiological risk.
The combination of sedation (causing lethargy) and topical throat anesthesia (suppressing the gag reflex) creates a severe risk for aspiration of oral secretions or emesis.
Aspiration can lead to airway obstruction, hypoxia, and aspiration pneumonia, making airway protection the top priority based on the ABCs (Airway, Breathing, Circulation).
3
Evaluate the nursing actions to mitigate the identified risk.
Keeping the client NPO directly prevents aspiration until the protective gag reflex is fully restored. The other options introduce new risks or are clinically inappropriate.
This action directly addresses the highest priority physiological need and prevents a life-threatening complication.

Key Concept

Post-procedure airway protection and aspiration prevention
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Topics

Reduction of Risk Potential

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