A client had an endoscopic retrograde papillotomy for stone removal and has returned to the nursing unit. The client is asking for ice chips. What assessment takes priority? The nurse should assess the client's
A) bowel sounds.
B) gag reflex.
C) sedation level.
D) vital signs.

Question

Quizplus · Accepted Answer

During this procedure, a local anesthetic is sprayed at the back of the client's throat to facilitate passing the endoscope. The nurse should carefully check for the return of the gag reflex before allowing oral intake. This is the priority assessment as the client is asking for ice chips. The client has probably received sedation for the procedure, making an assessment of sedation level important as well. Vital signs are monitored frequently post-procedure. Bowel sounds are the last priority as the client did not receive general anesthesia.

A Client Had an Endoscopic Retrograde Papillotomy for Stone Removal