A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take in preparation for the procedure?

Shave the client from axillae to groin.

Administer a cleansing enema.

Have the client drink contrast medium.

Ensure the signed consent is in the medical record.

Answer and Explanation

The Correct Answer is D

Choice A reason: Shaving the client from axillae to groin is not necessary, as it has no relation to the procedure and can cause skin irritation or infection.

Choice B reason: Administering a cleansing enema is not required, as it does not affect the upper gastrointestinal tract that is examined by the procedure. The client should fast for at least 6 hours before the procedure to ensure an empty stomach.

Choice C reason: Having the client drink contrast medium is not indicated, as it can interfere with the visualization of the mucosa and lesions by the endoscope. The client may receive a local anesthetic spray or gargle to numb the throat and a sedative to relax and reduce discomfort during the procedure.

Choice D reason: Ensuring the signed consent is in the medical record is an essential action, as it indicates that the client has been informed about the purpose, risks, benefits, and alternatives of the procedure and has agreed to undergo it voluntarily.

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Correct Answer is B

Explanation

Choice A reason: The thigh-high stockings should reach just below the gluteal folds, not above them. If the stockings are too high, they can cause constriction and impair circulation.

Choice B reason: Reapplying the stockings before getting out of bed is an appropriate action. The client should remove the stockings at night and inspect the skin for any signs of irritation or breakdown. The client should also elevate the legs for 15 minutes before putting on the stockings to reduce edema and improve venous return.

Choice C reason: Flexing the toes when applying the stockings is not an appropriate action. The client should point the toes and foot downward when applying the stockings to prevent wrinkles or folds that can cause pressure ulcers.

Choice D reason: Rolling down knee-high stockings slightly to provide comfort is not an appropriate action. The client should avoid rolling or folding the stockings as this can create a tourniquet effect and impair blood flow.

A. Chest x-ray showing cardiomegaly B. PaCO2 55 mmHg C. Potassium level 4.5 mEq/L D. Urinary output of 1,000 mL in 12 hr

Correct Answer is B

Explanation

Choice A reason: Chest x-ray showing cardiomegaly is not a new finding for the client who has heart failure, as it indicates enlargement of the heart due to increased workload and pressure on the cardiac chambers.

Choice B reason: PaCO2 55 mmHg is an abnormal finding for the client who has heart failure, as it indicates respiratory acidosis, which is a condition where the lungs cannot eliminate enough carbon dioxide and the blood becomes too acidic. This can be caused by pulmonary edema, which is a complication of heart failure that impairs gas exchange and ventilation.

Choice C reason: Potassium level 4.5 mEq/L is a normal finding for the client who has heart failure, as it indicates adequate electrolyte balance and renal function.

Choice D reason: Urinary output of 1,000 mL in 12 hr is a normal finding for the client who has heart failure, as it indicates adequate fluid status and cardiac output.

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A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take in preparation for the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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