Nokea
The health care provider sees a patient at 10 A.M. and writes a prescription for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which of the following actions that are included in the agency protocol for ERCP should the nurse take first?
- A. Place the patient on NPO status.
- B. Administer sedative medications.
- C. Ensure the consent form is signed.
- D. Explain the procedure to the patient.
Correct Answer: A
Rationale: The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse's initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO.
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The nurse is caring for a patient following a needle biopsy of the liver at the bedside. Which of the following actions should the nurse implement?
- A. Put pressure on the biopsy site using a sandbag.
- B. Elevate the head of the bed to facilitate breathing.
- C. Place the patient on the right side with the bed flat.
- D. Check the patient's post-biopsy coagulation studies.
Correct Answer: C
Rationale: After a biopsy, the patient lies on the right side for a minimum of two hours with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site.
The nurse is obtaining a history from a patient who is admitted with jaundice. Which of the following statements is most indicative of a need for patient teaching?
- A. I used cough syrup several times a day last week.
- B. I take a baby Aspirin every day to prevent strokes.
- C. I need to take an antacid for indigestion several times a week.
- D. I use acetaminophen every 4 hours for persistent pain.
Correct Answer: D
Rationale: Persistent use of high doses of acetaminophen can be hepatotoxic and may have caused the patient's jaundice. The other patient statements require further assessment by the nurse, but do not indicate a need for patient education.
Which of the following information collected by the nurse when caring for a patient who has just arrived in the recovery area after an esophagogastroduodenoscopy (EGD) is most important to communicate to the health care provider?
- A. The patient is very sleepy.
- B. The oral temperature is 38.7°C (101.7°F).
- C. The apical pulse is 104 beats/minute.
- D. The patient complains of a sore throat.
Correct Answer: B
Rationale: A temperature elevation may indicate that a perforation has occurred. The other assessment data are normal immediately after the procedure.
The nurse is caring for a patient who has just had a colonoscopy. Which of the following symptoms should alert the nurse that a perforation has occurred?
- A. Malaise
- B. Abdominal distension
- C. Hypertension
- D. Bradycardia
- E. Tenesmus
Correct Answer: A,B,E
Rationale: Following a colonoscopy the nurse should observe the patient for rectal bleeding and signs of perforation (e.g. malaise, abdominal distension, tenesmus). Hypertension and bradycardia are not typical signs of perforation.
During change-of-shift report, the nurse receives the following information about a patient who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure?
- A. The patient has a permanent pacemaker to prevent bradycardia.
- B. The patient is worried about discomfort during the examination.
- C. The patient has had an allergic reaction to shellfish and iodine in the past.
- D. The patient refused to drink the ordered polyethylene glycol.
Correct Answer: D
Rationale: If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure should be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging (MRI), but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient's anxiety about discomfort.