Question

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes no active gag reflex. What nursing action is a priority?

A) Document the absence of a gag reflex.
B) Encourage the client to drink water.
C) Administer a medication to stimulate the gag reflex.
D) Perform a complete physical examination.

Answer 1

The priority nursing action after a transesophageal echocardiogram if the patient has no active gag reflex is airway safety and close monitoring until the gag reflex returns, not encouraging the client to drink water or administering medication to stimulate the gag reflex, but documenting the absence of the gag reflex is essential.

Step-by-step explanation:

After a client returns from a transesophageal echocardiogram and is observed to have no active gag reflex due to the oral topical anesthetic, the nursing action that is a priority is to ensure airway safety because there is a risk of aspiration. The nurse should not encourage the client to drink water because without an active gag reflex, the client is at risk of aspiration, which can lead to pneumonia or other serious complications. Administering a medication to stimulate the gag reflex is not a standard or immediate intervention post anesthesia or sedation. Instead, the nurse should monitor the client closely until the gag reflex returns and document the absence of a gag reflex as part of the post-procedural observations. A full physical examination is not the immediate priority but should occur as part of ongoing post-procedural care.