Nokea
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.
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The nurse is working in a diagnostic testing unit focusing on gastrointestinal studies. For which testing procedure is the nurse correct to assess the gag reflex before offering fluids?
- A. Esophagogastroduodenoscopy
- B. Sigmoidoscopy
- C. Peritoneoscopy
- D. Colonoscopy
Correct Answer: A
Rationale: The nurse is correct to assess the gag reflex prior to offering fluids for a client having an esophagogastroduodenoscopy (EGD). The other options are lower gastrointestinal studies typically requiring a bowel preparation.
The nurse is examining the skin of a client who is dehydrated due to fluid losses from the gastrointestinal tract. Which would be the most important assessment for the nurse to make?
- A. Checking if the skin is discolored
- B. Checking if the mucous membranes are dry
- C. Examining the sclera if it is yellow
- D. Observing for distended abdominal veins
Correct Answer: B
Rationale: Mucous membranes may be dry, and skin turgor may be poor in clients suffering from dehydration as a result of fluid losses from the GI tract. Checking the skin for discoloration and inspecting the sclera if it is yellow is taken into consideration when the client could have symptoms of jaundice, not fluid losses. Distended abdominal veins are not associated with dehydration.
The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?
- A. A complete blood count including differential
- B. Serum antibodies for H. pylori
- C. A sigmoidoscopy
- D. Gastric analysis
Correct Answer: B
Rationale: Helicobacter pylori, a bacterium, is believed to be responsible for the majority of peptic ulcers. Blood tests are used to determine whether there are antibodies to H. pylori in the blood. A complete blood count with differential can indicate bleeding and infection associated with a bleeding ulcer. A sigmoidoscopy assesses the lower gastrointestinal tract. Gastric analysis is more common in analyzing gastric fluid in determining problems with the secretory activity of the gastric mucosa.
The nurse is caring for a client experiencing diarrhea. When teaching about the site in the body where water and electrolytes are absorbed, the nurse is most correct to instruct on which location?
- A. The small intestine
- B. The stomach
- C. The large intestine
- D. The cecum
Correct Answer: C
Rationale: The nurse is correct in instructing the client that water and electrolytes are mainly absorbed in the large intestine. The other options are not the best site for absorption.
The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment?
- A. Drowsiness
- B. Abdominal distention
- C. Sore throat
- D. Thirst
Correct Answer: B
Rationale: The nurse is correct to fully assess the client experiencing abdominal distention following an esophagogastroduodenoscopy (EGD). Abdominal distention could indicate complications such as perforation and bleeding. The client experiences drowsiness from the sedative during the early recovery process and a sore throat from passage of the scope. The client may also experience thirst because the client has not had liquids for a period of time.