Free NCLEX Practice Questions.
Take Practice Question # 379
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1. Question
The client has undergone esophagogastroduodenoscopy. The nurse places highest priority on which item as part of the client’s care plan?
Correct
Answer & Rationale.
Option 4 is correct
Rationale: The nurse places highest priority on assessing for return of the gag reflex. This assessment addresses the client’s airway. The nurse also monitors the client’s vital signs and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client’s airway is the priority.
Incorrect
Answer & Rationale.
Option 4 is correct
Rationale: The nurse places highest priority on assessing for return of the gag reflex. This assessment addresses the client’s airway. The nurse also monitors the client’s vital signs and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client’s airway is the priority.
NCLEX Review:
Need more questions for better practice to clear mine test…question were gud with nice explanation like it.