Nokea
The nurse is caring for a client following gastrointestinal diagnostic testing. The client verbalizes feeling shame due to having frequent gas. Which nursing suggestion is best?
- A. Having gas following the procedure is normal. Expel the gas to decrease discomfort.
- B. Do not be ashamed. Everyone has gas following the procedure.
- C. The nursing staff is used to having clients with gas due to the procedure completed.
- D. Nurses anticipate that client will have gas following the procedure and provide privacy.
Correct Answer: A
Rationale: The nurse is correct to tell the client that this experience is normal and encourage the client to release the gas to decrease pain and discomfort. Providing information relieving the embarrassment and stating the benefit of the action is most helpful.
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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 instructing a client prior to a colonoscopy. The client asks, 'Why do I have to drink this disgusting liquid?' The nurse is most correct to verbalize the goal of the oral preparation as which of the following?
- A. To allow ease of passage of the scope through the colon
- B. To decrease pain associated with fecal matter being pressed against the colon wall
- C. To cleanse the bowel to promote clear visualization of structures
- D. To eliminate gas from the internal portion of the colon
Correct Answer: C
Rationale: The goal of the oral preparation is to eliminate fecal matter to visualize the colon structures. Having a clean colon free of fecal matter does allow for ease of passage of the scope and eliminates gas. The client is sedated throughout the procedure so does not experience pain.
The nurse is assessing a client of color for jaundice. In which location(s) would the nurse assess for discoloration? Select all that apply.
- A. The sclera
- B. The gums
- C. The hands
- D. The nails
- E. The hard palate
- F. The conjunctiva
Correct Answer: A,B,E,F
Rationale: In very dark-skinned clients, the nurse inspects the hard palate, gums, conjunctiva, and surrounding tissues for discoloration. If the skin appears jaundiced, the nurse inspects the sclera if it is yellow.
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.