Nokea
A client is scheduled for an esophagogastroduodenoscopy (EGD) to detect lesions in the gastrointestinal tract. The nurse would observe for which of the following while assessing the client during the procedure?
- A. Signs of perforation
- B. Client's ability to retain the barium
- C. Client's tolerance for pain and discomfort
- D. Gag reflex
Correct Answer: C
Rationale: The nurse must assess the client's tolerance for pain and discomfort during the procedure. The nurse should assess the signs of perforation and the gag reflex after the procedure of EGD and not during the procedure. Assessing the client's level for retaining barium is important for a diagnostic test that involves the use of barium. EGD does not involve the use of barium.
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When assisting with preparing a client scheduled for a barium swallow, which instruction would be appropriate to include?
- A. Avoid smoking for at least 12 to 24 hours before the procedure.
- B. Take vitamin K before the procedure.
- C. Take three cleansing enemas before the procedure.
- D. Avoid the intake of red meat before the procedure.
Correct Answer: A
Rationale: The nurse should instruct the client to avoid smoking for at least a day before the procedure of barium swallow because smoking stimulates gastric motility. The client is advised to take vitamin K before a liver biopsy and instructed to take three cleansing enemas before a barium enema. Instruction to avoid red meat would be appropriate for a client who is having a Hemoccult test.
The nurse is providing community education at the mall. The nurse is instructing on the muscular tube that connects the mouth to the stomach. The nurse outlines this structure on a drawing and labels it with which of the following?
- A. Pharynx
- B. Pylorus
- C. Esophagus
- D. Ileum
Correct Answer: C
Rationale: The esophagus begins at the base of the pharynx and ends at the opening of the stomach. Layers of muscular tissue surround the esophagus. The pharynx is part of the throat situated immediately inferior to the mouth and nasal cavity. The pylorus is the region of the stomach that connects to the duodenum. The ileum is a portion of the small intestine.
The nurse is caring for a client following a colonoscopy. During the procedure, two medium-sized polyps were removed. Which nursing assessment in the recovery area is a priority?
- A. Assessment of level of consciousness
- B. Hemoccult test of stool
- C. Vital signs
- D. Ability to tolerate liquids
Correct Answer: C
Rationale: The nurse is correct in assessing vital signs following a colonoscopy with polyp removal as a priority. Vital signs of an increased pulse rate and falling blood pressure can indicate a perforation and bleeding. If a perforation occurs and is not addressed at an early stage, the client's level of consciousness can become affected. There would be no reliable stool present in the bowel to Hemoccult test due to the cleansing agent and potential bleeding from the polyp removal. The ability to tolerate fluids relates to the sedation process and is not as high of a priority.
The nurse is reviewing the results of a Hemoccult test with the client. Which question(s) asked by the nurse is important in screening for the potential of a false-positive result? Select all that apply.
- A. Do you take an iron supplement on a daily basis?
- B. Does your diet include a moderate amount of vitamin C?
- C. Are you prescribed regular strength aspirin daily?
- D. Can you tell me the amount of alcohol that you drink on an average week?
- E. When was the last time that you included red meat in your diet?
Correct Answer: C,D,E
Rationale: When obtaining a positive Hemoccult test, the client needs to be screened for a false-positive test result. Substances that may cause a false-positive include red meat, aspirin, and excessive alcohol. Screening for the frequency and amount of these are important. False-negative results are screened in individuals who ingest ascorbic acid and iron supplements.
Which nursing instruction is correct to provide the client following a barium enema?
- A. The client will maintain a low residue diet.
- B. The stools may be a white or clay colored.
- C. Sips of fluid may be increased if tolerated.
- D. An enema will be used to clear the bowel.
Correct Answer: B
Rationale: It is important to instruct the client that it is normal to have a white- or clay-colored stool following the barium enema. The client should report the color of the stool to the nurse. A progression of clay-colored stools to brown-colored stools should be noted. The client is prescribed a low-residue diet before the procedure. An increased fluid intake is offered to eliminate the barium from the bowel. The client is encouraged to move the bowel independently.