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Which of the following actions by a nursing student when caring for a patient who has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD) requires that the RN intervene?
- A. Offering the patient a glass of water
- B. Positioning the patient on the right side
- C. Checking the vital signs every 30 minutes
- D. Swabbing the patient's mouth with cold water
Correct Answer: A
Rationale: Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. The patient should be NPO for 2-4 hours. Assessment for return of the gag reflex should be done prior to administering any fluids by mouth. The other actions by the student are appropriate.
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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 information obtained by the nurse when admitting a patient who is scheduled for an ultrasound of the gallbladder indicates that the ultrasound may need to be rescheduled?
- A. The patient has a permanent gastrostomy tube.
- B. The patient took a laxative the previous evening.
- C. The patient ate a low-fat bagel an hour previously.
- D. The patient had a high-fat meal the previous evening.
Correct Answer: C
Rationale: Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient should be NPO for 8-12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study.
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 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.
The nurse is listening to a patient's abdomen. Which of the following findings indicate a need for a focused abdominal assessment?
- A. Loud gurgles
- B. High-pitched gurgles
- C. Absent bowel sounds
- D. Frequent clicking sounds
Correct Answer: C
Rationale: Absent bowel sounds are abnormal and require further assessment by the nurse. The other sounds may be heard normally.