CH. 52 Evolve NCLEX

A client is scheduled for a colonoscopy. What does the nurse tell the client to do before the procedure is performed? "Begin a clear liquid diet at least 24 hours before the test." "Do not eat or drink anything for 12 hours before the test." "Give yourself tap water enemas until the fluid returns are clear." "Be sure to take all currently prescribed medications prior to the procedure."

"Begin a clear liquid diet at least 24 hours before the test." The nurse tells the client to be on a clear liquid diet for at least 24 hours to cleanse the bowel before a colonoscopy.The client must be NPO (except for water) 4 to 6 hours before a colonoscopy, not 12 hours. Also, the client needs to avoid aspirin, anticoagulants, and antiplatelet drugs for several days before the procedure. Diabetic clients need to check with their health care provider about drug therapy requirements on the day of the test because they are NPO. The client would not give him/herself a tap water enema. Clients must not take all currently prescribed medications without first checking with their doctor.

The nurse is educating a group of older adults about screening for colorectal cancer. Which statement by a group member indicates the need for further clarification about these guidelines? "A barium enema every 5 years is a screening option." "I will need to have a routine colonoscopy every 5 years." "My routine flexible sigmoidoscopy every 5 years is OK." "The 'virtual' colonoscopy every 5 years is acceptable."

"I will need to have a routine colonoscopy every 5 years." The 2015 guidelines indicate that routine screening with colonoscopy is performed every 10 years, not every 5 years.Other options are performed at 5-year intervals. A barium enema every 5 years is a screening option. A flexible sigmoidoscopy and a "virtual" colonoscopy every 5 years are also acceptable for screening. A "virtual" colonoscopy or CT colonography is a noninvasive imaging procedure that takes multidimensional views of the entire colon.

The outpatient clinic nurse is caring for a recovering client who had a colonoscopy. The client asks for a drink. How does the nurse respond to this request? "After I hear bowel sounds, you can have a drink." "Twenty minutes after the procedure was completed, you may have some liquids." "When you are able to pass flatus (gas), you can have a drink." "You can have fluids when you get home and are settled."

"When you are able to pass flatus (gas), you can have a drink." Fluids are permitted after the client's peristalsis has returned, which is validated by the client's passing flatus (p. 34).Ability to pass flatus (gas) is more reliable than auscultation of bowel sounds when assessing a client's status to drink after a colonoscopy. There is no set time period after the procedure that is considered safe for the client to have something to drink. The client will not be discharged home without the nurse determining that peristalsis has returned. The client must report that he or she is passing flatus to go home; therefore, the client should be given a drink before being sent home.

Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis A 36-year-old who needs teaching about an endoscopic retrograde cholangiopancreatography A 40-year-old who will need administration of IV midazolam hydrochloride (Versed) during an upper endoscopy A 46-year-old who was recently admitted with abdominal cramping and diarrhea of unknown causes

A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis Nasogastric tube insertion is included in LPN/LVN education and is an appropriate task for an experienced LPN/LVN.Assessment and client teaching would be done by an RN. IV hypnotic medications would be administered by an RN.

Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) clinic? A 38-year-old who needs discharge instructions after having an endoscopic retrograde cholangiopancreatography (ERCP) A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy A 43-year-old recently admitted with nausea, abdominal pain, and abdominal distention A 50-year-old with epigastric pain who needs conscious sedation during a scheduled endoscopy procedure

A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy is the least complicated client. This client would be assigned to the float nurse who would have the experience and training to adequately care for this client. A clinic nurse typically cares for clients with chronic conditions.Discharge instructions following an ERCP, assessment of an admitted acutely ill client, and monitoring a client who is receiving conscious sedation would be accomplished best by nurses with experience in caring for adults with acute GI problems.

While working in the outpatient procedure unit, the RN is assigned to these clients. Which client does the nurse assess first? A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) A 54-year-old who is ready for discharge following a colonoscopy A 58-year-old who has just arrived for basal gastric secretion and gastric acid stimulation testing A 60-year-old with questions about an endoscopic ultrasound examination

A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) ERCP requires conscious sedation, so the client needs immediate assessment of respiratory and cardiovascular status. The endoscopic procedure and nursing care for a client having an ERCP are similar to those for the EGD procedure, except that the endoscope is advanced farther into the duodenum and into the biliary tractA 54-year old client being discharged after a colonoscopy, a 58-year old client who is going to have a gastric acid test, and a 60-year old client with questions about an endoscopic ultrasound examination are not at risk for depressed respiratory status.

A nurse is preparing a health teaching session about early detection of colorectal cancer. Which test should the nurse include? Select all that apply. A. Colonoscopy every 10 years B. Single sample fecal immunochemical test (FIT) C. Flexible sigmoidoscopy every 5 years D. Stool DNA test (sDNA) every 3 years E. Double-contrast barium enema every 5 years F. Take-home yearly guaiac fecal occult blood test (gFOBT)

A. Colonoscopy every 10 years C. Flexible sigmoidoscopy every 5 years D. Stool DNA test (sDNA) every 3 years E. Double-contrast barium enema every 5 years F. Take-home yearly guaiac fecal occult blood test (gFOBT)

The nurse is assessing an alert client who had abdominal surgery yesterday. What method provides the most accurate data about resumption of peristalsis in the client? -Asking the client whether he or she has passed flatus (gas) within the previous 12 to 24 hours. (p. 17) -Auscultating bowel sounds in all abdominal quadrants -Counting the number of bowel sounds in each abdominal quadrant over one minute. -Observing the abdomen for symmetry and distention

Asking the client whether he or she has passed flatus (gas) within the previous 12 to 24 hours. The best and most reliable method for assessing the return of peristalsis following abdominal surgery is the client's report of passing flatus within the past 8 hours or stool within the past 12 hours.Although auscultation and counting the number of sounds was once a method of assessing for bowel activity, it is no longer considered the most effective method. Observing the abdomen is one method of examining a client's abdomen, but it is not a reliable way to assess for resumption of activity after surgery.

The nurse is performing a physical assessment on a client's abdomen. The nurse inspects the abdomen and finds it asymmetrical, with a nonpulsating mass in the RUQ. What is the priority nursing intervention? A. Document the findings in the electronic health record. B. Auscultate for bowel sounds and bruits. C. Lightly palpate the mass. D. Notify the primary health care provider of the findings.

B. Auscultate for bowel sounds and bruits.

When taking a history for a patient with GI problems, which daily client behavior requires further nursing assessment? Select all that apply. A. Eats multiple servings of vegetables B. Takes 800 mg of ibuprofen for arthritic pain C. Walks 30 minutes D. Chews tobacco E. Takes senna to assist with bowel movements F. Listens to music to promote relaxation

B. Takes 800 mg of ibuprofen for arthritic pain D. Chews tobacco E. Takes senna to assist with bowel movements

What is a common gastrointestinal problem that older adults experience more frequently as they age? Decreased hydrochloric acid levels Excess lipase production Increased liver size Increased peristalsis

Decreased hydrochloric acid levels In older adults, decreased hydrochloric acid levels (hypochlorhydria) results from atrophy of the gastric mucosa.A decrease in lipase production results from calcification of pancreatic vessels. A decrease in the number and size of hepatic cells leads to decreased liver weight and mass. Peristalsis decreases, and nerve impulses are dulled.

A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? Assesses the abdomen in the following sequence: inspection, palpation, percussion, auscultation Examines the RUQ of the abdomen last following all other assessment techniques. Have the client lie in a supine position with legs straight and arms at the sides Gently palpates any bulging mass and documents findings.

Examines the RUQ of the abdomen last following all other assessment techniques. If the client reports pain in the RUQ, the nurse would examine this area last in the examination sequence. This sequence prevents the client from tensing abdominal muscles because of the pain, which would make the examination difficult.The sequence for examining the abdomen is inspection, auscultation, percussion, and then palpation. This sequence prevents the increase in intestinal activity and bowel sounds caused by palpation and percussion. The client would be positioned supine with the knees bent, while keeping the arms at the sides to prevent tensing of the abdominal muscles. If a bulging, pulsating mass is present during assessment of the abdomen, do not touch the area because the client may have an abdominal aortic aneurysm, a life-threatening problem. Notify the health care provider of this finding immediately!

A client had a routine sigmoidoscopy with a tissue biopsy. What postprocedure complication would the nurse report to the health care provider? Gas and flatulence Excessive bleeding Nausea and vomiting Severe rectal pain

Excessive bleeding Excessive or heavy bleeding is a possible complication following a sigmoidoscopy. It must be reported immediately to the health care provider.Nausea, vomiting, and severe rectal pain are not common complications of sigmoidoscopy. Gas and flatulence are expected assessment findings post-sigmoidoscopy (p. 36)

The nurse practitioner is performing an abdominal assessment on a newly admitted client. In which order should the nurse proceed with assessment technique? Auscultation, percussion, palpation, inspection Inspection, auscultation, percussion, palpation Palpation, percussion, inspection, auscultation Percussion, auscultation, palpation, inspection

Inspection, auscultation, percussion, palpation The assessment technique proceeds as inspection, auscultation, percussion, palpation. This sequence is different from that used for other body systems. It is used so that palpation and percussion do not increase intestinal activity and bowel sounds. Nurse generalists may perform inspection, auscultation, and light palpation; percussion and deep palpation may be done by advanced practice nurses.Inspection must be the first assessment technique. Options beginning with auscultation, palpation, or percussion are incorrect.

The nurse is assessing a client who has come to the emergency department with acute abdominal pain. The client is very thin and the nurse observes visible peristaltic movements when inspecting the abdomen. What does the nurse suspect? Acute diarrhea Aortic aneurysm Intestinal obstruction Pancreatitis

Intestinal obstruction The nurse would suspect an intestinal obstruction related to peristaltic movements. Peristaltic movements are rarely seen except in thin clients. This needs to be reported to the HCP.Acute diarrhea does not cause visible peristaltic movements. Aortic aneurysm may cause a bulging, pulsatile mass. Pancreatitis is characterized by severe pain.

Which substance, produced in the stomach, facilitates the absorption of vitamin B12? Glucagon Hydrochloric acid Intrinsic factor Pepsinogen

Intrinsic factor Intrinsic cells are produced by the parietal cells in the stomach. This substance facilitates the absorption of vitamin B12. Absence of intrinsic factor causes pernicious anemia.Glucagon, which is produced by the alpha cells in the pancreas, is essential for the regulation of metabolism. Parietal cells secrete hydrochloric acid, but this does not facilitate the absorption of vitamin B12. Pepsinogen is secreted by the chief cells; pepsinogen is a precursor to pepsin, a digestive enzyme.

The nurse is assessing a client who comes to the emergency department with acute abdominal pain. The nurse notes a bulging, pulsating mass when inspecting the abdomen. Which action by the nurse is correct? Auscultate the abdomen to determine the presence of bowel sounds. Notify the provider about this finding immediately. Palpate the client's abdomen to determine the outlines of the mass. Question the client about recent stool habits.

Notify the provider about this finding immediately. The nurse needs to immediately notify the health care provider because a bulging, pulsating mass may indicate an abdominal aortic aneurysm requiring emergency actions.Palpating the abdomen or even touching the abdomen with a stethoscope may cause this to rupture, which would be a life-threatening emergency. Because this is a potential life-threatening situation, questioning the client about stool habits is not appropriate.

After a colonoscopy, a client reports severe abdominal pain. The nurse obtains these data: temperature 100.2°F (37.9°C), pulse 122 beats/min, blood pressure 100/45 mm Hg, respirations 44 breaths/min, and O2 saturation 89%. Which request from the health care provider does the nurse implement first? Give cefazolin (Ancef) 500 mg IV. Infuse normal saline at 200 mL/hr. Give morphine sulfate 2 mg IV. Provide oxygen at 6 L/min per nasal cannula.

Provide oxygen at 6 L/min per nasal cannula. The first request the nurse complies with is to place the client on oxygen. This is the most immediate concern because it involves the client's respiratory status. Based on the data given, the client may be experiencing complications of colonoscopy such as bleeding or perforation.An antibiotic request is important but is not the first priority. Fluid supplementation is important, but the client's oxygen saturation level places the client's respiratory status as the priority. The client's need for analgesia should be delayed until respiratory status is addressed. Morphine depresses respiratory status and therefore might not be the right choice for this client.

A client arrives at the emergency department with acute abdominal pain in the left lower quadrant. In which order does the nurse examine and assess the client's abdomen? (left lower quadrant (LLQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and right upper quadrant (RUQ))? LLQ, RLQ, LUQ, RUQ LUQ, LLQ, RUQ, RLQ RLQ, LLQ, RUQ, LUQ RUQ, LUQ, RLQ, LLQ

RUQ, LUQ, RLQ, LLQ The LLQ would be the last area assessed for this client. Abdominal examination usually begins at the client's right side and proceeds in a systematic fashion: RUQ, LUQ, RLQ, LLQ. However, if the client is experiencing pain in a specific quadrant, that area should be assessed last in the examination sequence. This action prevents the client from tensing abdominal muscles because of the pain, which would make the examination difficult.The options that do not assess the quadrant where the pain presents last are incorrect.

Which factors place a client at risk for gastrointestinal (GI) problems? Select all that apply. Eating a high-fiber diet Smoking a half-pack of cigarettes per day Socioeconomic status Some herbal preparations Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

Smoking a half-pack of cigarettes per day Socioeconomic status Some herbal preparations Use of nonsteroidal anti-inflammatory drugs (NSAIDs) Smoking or any tobacco use places a client in a higher-risk category for GI problems. Socioeconomic status can also influence the risk for GI problems; clients may not be able to afford to seek care or treatment and may put off seeking help. Some herbal preparations contribute to GI problems, such as Ayurvedic herbs, which can affect appetite, absorption, and elimination. NSAIDs can predispose clients to peptic ulcer disease or GI bleeding.High-fiber diets are generally believed to be healthy for most clients.