A client with diverticular disease has just returned from a colonoscopy. While conducting an abdominal assessment, the nurse monitors for which of the following as an initial sign of a possible complication of the procedure?
Guarding and rebound tenderness
Nausea and vomiting
Diarrhea
Hyperactive bowel sounds
The Correct Answer is A
Choice A reason: Guarding and rebound tenderness are signs of peritonitis, which is a serious complication of colonoscopy. Peritonitis is an inflammation of the peritoneum, the membrane that lines the abdominal cavity. It can be caused by perforation or puncture of the colon during the colonoscopy, which allows bacteria and fecal matter to enter the peritoneal space. The nurse should monitor the client for signs of peritonitis, such as abdominal pain, rigidity, fever, and leukocytosis.
Choice B reason: Nausea and vomiting are not specific signs of a complication of colonoscopy. They may be caused by other factors, such as the sedation, the bowel preparation, or the ingestion of food or fluids after the procedure. Nausea and vomiting may also be symptoms of other conditions, such as gastroenteritis, food poisoning, or pregnancy.
Choice C reason: Diarrhea is not a sign of a complication of colonoscopy. Diarrhea may be a normal consequence of the bowel preparation, which involves taking laxatives or enemas to clear the colon before the procedure. Diarrhea may also be caused by other factors, such as the ingestion of food or fluids after the procedure, or the presence of an underlying bowel disorder, such as irritable bowel syndrome or inflammatory bowel disease.
Choice D reason: Hyperactive bowel sounds are not a sign of a complication of colonoscopy. Hyperactive bowel sounds may indicate increased peristalsis, which is the movement of the digestive tract. Hyperactive bowel sounds may be a normal response to the bowel preparation, the ingestion of food or fluids after the procedure, or the stimulation of the colon during the colonoscopy. Hyperactive bowel sounds may also be present in conditions such as diarrhea, gastroenteritis, or intestinal obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Dark-colored stools are an adverse effect of orlistat, a medication that blocks the absorption of fat in the intestines. The unabsorbed fat can cause the stools to become oily, foul-smelling, and dark in color. This can indicate a serious condition called steatorrhea, which can lead to malnutrition and vitamin deficiencies.
Choice B reason: Constipation is not an adverse effect of orlistat. In fact, orlistat can cause the opposite problem of diarrhea, especially if the client consumes too much fat in their diet. Constipation may be caused by other factors, such as dehydration, lack of fiber, or medication side effects.
Choice C reason: Nausea is not an adverse effect of orlistat. Nausea may be a symptom of other conditions, such as gastritis, gastroenteritis, or pregnancy. Nausea may also be caused by other medications, such as antibiotics, opioids, or chemotherapy drugs.
Choice D reason: Abdominal pain is not an adverse effect of orlistat. Abdominal pain may be a sign of other conditions, such as appendicitis, gallstones, or kidney stones. Abdominal pain may also be caused by other medications, such as NSAIDs, steroids, or oral contraceptives.
Correct Answer is D
Explanation
Choice A reason: Slowing the rate to 50 mL/hr is not an appropriate action by the nurse before calling the physician to clarify the order. This could cause the client to become more hypovolemic, which is a condition where there is a decreased volume of blood in the body. Hypovolemia can lead to shock, organ failure, and death.
Choice B reason: Slowing the rate to 20 mL/hr is not an appropriate action by the nurse before calling the physician to clarify the order. This could also cause the client to become more hypovolemic, which is a serious and life-threatening condition. The nurse should not reduce the IV fluid rate without a physician's order.
Choice C reason: Increasing the rate to 250 mL/hr is not an appropriate action by the nurse before calling the physician to clarify the order. This could cause the client to become more hypervolemic, which is a condition where there is an excess of fluid in the blood vessels. Hypervolemia can cause fluid overload, pulmonary edema, and heart failure.
Choice D reason: Continuing the rate at 125 mL/hr is an appropriate action by the nurse before calling the physician to clarify the order. This is a reasonable rate for a client who has a head injury and hypovolemia, as it can help restore the fluid balance and prevent cerebral edema. The nurse should not change the IV fluid rate without a physician's order.
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