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A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse instructs the client and family about the signs of potential complications, which include what problems? (Select all that apply.)
- A. Cholangitis
- B. Pancreatitis
- C. Perforation
- D. Sepsis
- E. Kidney stones
Correct Answer: A,B,C,E
Rationale: Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.
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A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching?
- A. Is a good thing I love oranges and cherry gelatin.
- B. My spouse will be here to drive me home.
- C. I should refrigerate the Gol/TELY before use.
- D. I will buy a case of Gonoxide before the prop.
Correct Answer: A
Rationale: The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure.
A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority?
- A. Auscultate the abdomen.
- B. Notify the provider immediately.
- C. Order an abdominal flat-plate x-ray.
- D. Palpate the abdomen to assess size.
Correct Answer: B
Rationale: The observation could indicate an abdominal aortic aneurysm, which could be life-threatening and should never be palpated. The nurse notifies the provider at once. An x-ray may be indicated, but it is not the priority. Auscultation is part of the assessment, but the nurse's priority action is to notify the provider.
The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.)
- A. Colon cancer
- B. Diverticulitis
- C. Inflammatory bowel disease
- D. Peptic ulcer disease
- E. Pernicious anemia
Correct Answer: A,B,C,D
Rationale: In adults, the most common cause of anemia is GI bleeding. This is commonly associated with colon cancer, diverticulitis, inflammatory bowel disease, and peptic ulcer disease. Pernicious anemia is not associated with GI bleeding.
A client had a colossoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best?
- A. Come to the clinic immediately for evaluation.
- B. Monitor the bleeding and call back if it worsens.
- C. Take an over-the-counter stool softener.
- D. Avoid strenuous activity for a week.
Correct Answer: B
Rationale: A small amount of bright red blood on the toilet paper after a colonoscopy with biopsy is not uncommon due to minor irritation or trauma from the procedure. The nurse should advise the client to monitor the bleeding and call back if it worsens, as this could indicate a more serious issue. Immediate clinic evaluation is not necessary for a small spot of blood. Stool softeners or activity restrictions are not directly relevant unless specified by the provider.
A client who has been taking antibiotics reports severe, watery diarrhea. About which test does the nurse teach the client?
- A. Colonoscopy.
- B. Enzyme-linked immunosorbent assay (ELISA) toxin A+B
- C. Ova and parasites
- D. Stool culture
Correct Answer: B
Rationale: Severe, watery diarrhea after antibiotic use may indicate Clostridioides difficile infection. The ELISA toxin A+B test is used to detect toxins produced by C. difficile. A colonoscopy, ova and parasites test, or stool culture are not typically warranted for this scenario unless further evaluation is needed.