A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority?
A) Listen to bilateral lung and bowel sounds.
B) Obtain the client's pulse and blood pressure.
C) Assist the client to the bathroom to void.
D) Check the client's gag and swallow reflexes.
Answer: D) Check the client's gag and swallow reflexes.
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A nurse is administering a medication at the bedside. Which of the following actions should be the first priority?
a. Document the administration of the medication. b. Establish the identity of the client. c. Recheck the medication label. d. Obtain orange juice for the client to take with the medication.
The nurse has written a goal for a postoperative appendectomy patient that reads: "The client will ambulate 40 feet in the hallway every day beginning the day after surgery." This goal might be considered as:
a. having too long of a time frame to achieve. b. having too short of a time frame to achieve. c. being too easy for the client to achieve. d. something that should be accomplished once the client returns home.
What is a priority intervention in planning care for the child with disseminated intravascular coagulation (DIC)?
a. Hospitalization at the first sign of bleeding b. Teaching the child relaxation techniques for pain control c. Management in the intensive care unit d. Provision of adequate hydration to prevent complications
A client is using prayer to assist in relieving stress. The use of prayer allows the client to:
A) cope. B) understand. C) plan. D) recover.