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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.
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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.
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 assessing an alert and independent older-adult patient in the clinic for malnutrition risk. Which of the following questions is best as the initial assessment question?
- A. How do you get to the grocery store to buy your food?
- B. Do you have any difficulty in preparing or eating food?
- C. Can you tell me the foods that you have eaten over the past 24 hours?
- D. Are you taking any medications that alter your taste or tolerance of foods?
Correct Answer: C
Rationale: This question is the most open-ended and will provide the best overall information about the patient's daily intake and risk for poor nutrition. The other questions may be asked, depending on the patient's response to the first question.
Which of the following assessment findings in a patient who is being admitted to the hospital is most important to report to the health care provider?
- A. Tympany on percussion of the abdomen
- B. Liver edge 3 cm below the costal margin
- C. Bowel sounds of 20/minute in each quadrant
- D. Aortic pulsations visible in the epigastric area
Correct Answer: B
Rationale: Normally the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. The other findings are within normal range for the physical assessment.
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.