Nokea
The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?
- A. Kidney
- B. Liver
- C. Spleen
- D. Stomach
Correct Answer: B
Rationale: Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting factors. The other organs are not directly related to this issue.
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A client is having an esophagealgrosodendonescoropy (EGD) and has been given midazolam hydrochloride (Vessel). The clients respiratory rate is 8 breaths/min. What action by the nurse is best?
- A. Administerin valoxone (Vessel).
- B. Call the Rapid Response Team.
- C. Provide physical stimulation.
- D. Ventilate with a bag-valre-mask.
Correct Answer: C
Rationale: For an EGD, clients are given mild sedation but should still be able to follow commands. For shallow or slow respirations after sedation is given, the nurse's first action is to provide physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for midazolam (Versed). The Rapid Response Team is not needed at this point. The client does not need manual ventilation.
A client had a colossoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best?
- A. Come to the clinic immediately for evaluation.
- B. Monitor the bleeding and call back if it worsens.
- C. Take an over-the-counter stool softener.
- D. Avoid strenuous activity for a week.
Correct Answer: B
Rationale: A small amount of bright red blood on the toilet paper after a colonoscopy with biopsy is not uncommon due to minor irritation or trauma from the procedure. The nurse should advise the client to monitor the bleeding and call back if it worsens, as this could indicate a more serious issue. Immediate clinic evaluation is not necessary for a small spot of blood. Stool softeners or activity restrictions are not directly relevant unless specified by the provider.
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 client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching?
- A. Is a good thing I love oranges and cherry gelatin.
- B. My spouse will be here to drive me home.
- C. I should refrigerate the Gol/TELY before use.
- D. I will buy a case of Gonoxide before the prop.
Correct Answer: A
Rationale: The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure.
A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse instructs the client and family about the signs of potential complications, which include what problems? (Select all that apply.)
- A. Cholangitis
- B. Pancreatitis
- C. Perforation
- D. Sepsis
- E. Kidney stones
Correct Answer: A,B,C,E
Rationale: Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.