A patient is recovering from an endoscopy with banding of esophageal varices. Which intervention would have the highest priority immediately following the procedure and until the patient is fully awake?
1. Determining if the patient is able to swallow
2. Irrigating the NG tube with saline to detect any additional bleeding
3. Maintaining the patient in the left lateral decubitus position
4. Monitoring the patient's vital signs every hour
3
Rationale 1: During endoscopy, patients may have a topical anesthetic sprayed to the throat area, which may impair swallowing. The nurse waits until the patient is awake to assess swallowing.
Rationale 2: Irrigation is done as needed to maintain patency.
Rationale 3: If the patient is not intubated, the nurse should position the patient in the left lateral decubitus position to protect the airway until the patient is fully awake. Airway protection is always top priority.
Rationale 4: The nurse monitors vital signs, including temperature and oxygen saturation and level of pain and consciousness, until the patient returns to baseline (typically every 10 to 15 minutes for 30 minutes to an hour, then per ICU protocol, or more frequently depending on acuity).
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