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 B
Explanation
Choice A reason: Calling the doctor for more antiemetic medication is not the best intervention for the nurse to facilitate. Antiemetics are drugs that prevent or reduce nausea and vomiting, but they may have side effects such as drowsiness, dry mouth, or constipation. The nurse should first try non-pharmacological measures to relieve the patient's nausea, such as giving small sips of water, providing a cool and quiet environment, or using aromatherapy.
Choice B reason: Giving the patient small sips of tepid water is the best intervention for the nurse to facilitate. Water can help hydrate the patient and dilute any stomach acid that may cause irritation. Tepid water is water that is slightly warm, which can be more soothing than cold or hot water. Small sips can prevent the patient from swallowing too much air, which can worsen nausea and vomiting.
Choice C reason: Helping the patient lay supine is not a good intervention for the nurse to facilitate. Supine means lying flat on the back, which can increase the risk of aspiration, or inhaling food or fluids into the lungs. Aspiration can cause pneumonia, a serious lung infection. The nurse should help the patient lay on their side, with their head elevated, to prevent aspiration and reduce pressure on the stomach.
Choice D reason: Showing the patient how to use the patient-controlled analgesia is not a relevant intervention for the nurse to facilitate. Patient-controlled analgesia is a system that allows the patient to self-administer pain medication through an IV pump. It has nothing to do with nausea and vomiting, and may even cause them as side effects. The nurse should monitor the patient's pain level and adjust the analgesia settings as needed, but not as a way to treat nausea.
Correct Answer is C
Explanation
Choice A reason: The upper right quadrant is not the correct location for McBurney's point. This quadrant contains the liver, gallbladder, right kidney, and part of the colon. Pain in this area may indicate problems with these organs, such as hepatitis, gallstones, or kidney infection.
Choice B reason: The upper left quadrant is not the correct location for McBurney's point. This quadrant contains the stomach, spleen, left kidney, and part of the colon. Pain in this area may indicate problems with these organs, such as gastritis, splenomegaly, or kidney stones.
Choice C reason: The lower right quadrant is the correct location for McBurney's point. This quadrant contains the appendix, right ovary, and right fallopian tube. McBurney's point is a point on the abdomen that is one-third of the distance from the right anterior superior iliac spine to the umbilicus. Pain in this area may indicate appendicitis, ovarian cyst, or ectopic pregnancy.
Choice D reason: The lower left quadrant is not the correct location for McBurney's point. This quadrant contains the sigmoid colon, left ovary, and left fallopian tube. Pain in this area may indicate problems with these organs, such as diverticulitis, ovarian torsion, or pelvic inflammatory disease.
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