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A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best?
- A. Ask the client about difficult allergies.
- B. Document this information on the chart.
- C. Insureat that the client has a ride home.
- D. Insureat that the client has a ride home.
Correct Answer: A
Rationale: PTC uses iodinated dye, so the client should be asked about seafood allergies, specifically to shellfish, as these may indicate a risk for iodine allergy. Documentation should occur, but this is not the priority. The client will need a ride home afterward if the procedure is done as an outpatient, but this is not the priority action.
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The options for colon cancer screening for people over the age of 50 include which of the following? (Select all that apply.)
- A. Colonoscopy every 10 years
- B. CT colonography
- C. Double-contrast barium enema
- D. Flexible sigmoidoscopy every 5 years
- E. Fecal occult blood test annually
Correct Answer: A,C,D
Rationale: Colonoscopy every 10 years, CT colonography, double-contrast barium enema, and flexible sigmoidoscopy every 5 years are standard options for colon cancer screening in people over 50. Fecal occult blood test annually is also a screening option, but it was not listed in the original document and is included here for completeness.
A client is recovering from an esophagealgroduoesoscopy (EGD) and requests something to drink. What action by the nurse is best?
- A. Provide a small sip of water.
- B. Assess the client's gag reflex.
- C. Remind the client to remain NPO.
- D. Tell the client to wait two hours.
Correct Answer: B
Rationale: The local anesthetic used during an EGD can impair the gag reflex. The nurse should assess the client's gag reflex to ensure it is intact before allowing fluids to prevent aspiration. Providing water, reminding the client to remain NPO, or waiting two hours are not appropriate until the gag reflex is confirmed.
A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important?
- A. Ask the client about recent exposure to illness.
- B. Collect the stool sample for the client.
- C. Include the date and time on the specimen container.
- D. Don gloves prior to collecting the sample.
Correct Answer: D
Rationale: To avoid possible exposure to infectious agents, the nurse dons gloves prior to handling any bodily secretions. Recent exposure to illness is not related to collecting a stool sample. The nurse can visually inspect the stool for food particles, but it still needs analysis in the laboratory. The container should be dated and timed, but safety for the staff and other clients comes first.
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.
A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this clients abdomen?
- A. Auscultate after palpating.
- B. Avoid any palpation.
- C. Palpate the RUQ last.
Correct Answer: C
Rationale: If pain is present in a certain area of the abdomen, that area should be palpated last to keep the client from tensing up, which could affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation to avoid altering bowel sounds.