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Zorluk: KolayReduction of Risk Potential

A nurse is caring for a client who has just returned to the medical-surgical unit following an esophagogastroduodenoscopy (EGD) performed with a topical anesthetic spray to the throat. Which action is the priority for the nurse to take to reduce the client's risk of a potential complication?

  1. Assess for the return of the gag reflex prior to offering ice chips or waterCevap
  2. B
    Position the client completely flat in bed to prevent a post-procedure headache
  3. C
    Auscultate all four abdominal quadrants for bowel sounds before assessing the airway
  4. D
    Delegate the task of providing the client's first post-procedure drink to the unlicensed assistive personnel (UAP)

Cevap

The nurse must assess for the return of the gag reflex before offering any oral fluids.
The correct action directly addresses the highest priority risk: aspiration. Because the throat is numbed with a topical anesthetic during an EGD, the gag reflex is temporarily absent. The nurse must verify its return before offering any oral intake to protect the client's airway and prevent aspiration pneumonia.

Adım Adım Çözüm

1
Identify the physiological effects of the procedure.
During an EGD, a topical anesthetic spray is used to numb the throat to suppress the gag reflex and allow scope insertion.
Understanding the procedure's localized effects is essential for anticipating post-operative safety risks.
2
Determine the primary risk associated with a numb throat.
An absent or diminished gag reflex significantly increases the risk of pulmonary aspiration if food or liquid is ingested.
Aspiration is a severe, potentially life-threatening complication that must be prevented.
3
Select the nursing intervention that directly mitigates this risk.
The nurse must verify that the topical anesthetic has worn off by assessing the gag reflex before allowing oral intake.
This specific assessment ensures the airway is protected during swallowing.

Anahtar Kavram

Prevention of aspiration following procedures involving topical throat anesthesia.
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Konular

Reduction of Risk Potential

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