A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy. Which of the following information should the nurse include in the teaching?

"You will be moderately sedated during the procedure."

"You will lie on your right side for the procedure."

"You may drink full liquids until 6 hours before the procedure."

"You should warm the liquid bowel preparation before drinking it."

Answer and Explanation

The Correct Answer is A

The correct answer is Choice a. "You will be moderately sedated during the procedure."

Choice A rationale: Colonoscopy is a common procedure used for both diagnostic and therapeutic purposes in gastroenterology. Moderate sedation, also known as conscious sedation, is typically administered to patients undergoing colonoscopy to ensure their comfort and cooperation during the procedure. This level of sedation allows the patient to maintain their protective reflexes and respond to verbal commands, while also reducing anxiety and discomfort. The sedative agents commonly used for colonoscopy include benzodiazepines such as midazolam and analgesics such as fentanyl. The nurse should emphasize the use of moderate sedation to the patient, reassuring them that they will be in a relaxed state throughout the procedure without compromising their safety.

Choice B rationale: The statement suggesting that the patient will lie on their right side for the procedure is incorrect. During a colonoscopy, patients are typically positioned on their left side with their knees drawn up towards their chest. This left lateral decubitus position facilitates the advancement of the colonoscope through the colon and provides better visualization for the healthcare provider performing the procedure. Placing the patient on the right side would not provide optimal positioning and may hinder the progress of the colonoscopy.

Choice C rationale: The information provided in statement c. is incorrect regarding the dietary restrictions before a colonoscopy. Prior to the procedure, patients are instructed to follow a clear liquid diet for 24 to 48 hours, depending on the healthcare provider's instructions. Clear liquids include water, clear broth, tea, coffee without milk or cream, strained fruit juices (such as apple or white grape juice), and sports drinks. Solid foods, as well as liquids that are not transparent, should be avoided during this preparatory period to ensure adequate bowel cleansing and visualization during the colonoscopy.

Choice D rationale: The recommendation to warm the liquid bowel preparation before consumption, as stated in option d., is incorrect. Bowel preparations typically consist of polyethylene glycol-based solutions, which are intended to be consumed at room temperature or chilled. Warming the solution could alter its composition and taste, potentially causing discomfort or nausea in the patient. It is essential for patients to follow the specific instructions provided by their healthcare provider or the product labeling regarding the administration of bowel preparation to ensure effective bowel cleansing before the colonoscopy.

Choice E rationale: Repeated for emphasis, the advice to warm the liquid bowel preparation before consumption is incorrect and redundant. Patients should adhere strictly to the instructions provided by their healthcare provider or the product labeling regarding the administration of bowel preparation. Warming the solution is not recommended and could compromise the effectiveness of the preparation, leading to suboptimal bowel cleansing and potentially impacting the accuracy of the colonoscopy results.

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Correct Answer is A

Explanation

Answer is a. Check for neck vein distention.

a. Check for neck vein distention: Correct. Assessing for neck vein distention is an essential intervention for a client receiving IV fluid replacement, especially for dehydration. Neck vein distention can indicate fluid overload, a potential complication of IV fluid therapy. By monitoring for this sign, the nurse can promptly recognize and intervene to prevent fluid overload-related complications such as pulmonary edema and hypertension. Regular assessment of neck vein distention provides valuable information about the client's fluid status and guides adjustments to the IV fluid infusion rate to maintain fluid balance and prevent adverse outcomes.

b. Offer oral fluids every 4 hr: This option is incorrect because offering oral fluids every 4 hours may not be appropriate for a client receiving IV fluid replacement for dehydration. IV fluid replacement is typically indicated when oral rehydration is insufficient or impractical, such as in cases of severe dehydration, altered consciousness, or gastrointestinal disturbances. The frequency and volume of oral fluid intake should be individualized based on the client's condition, fluid requirements, and ability to tolerate oral intake. Therefore, the nurse should prioritize IV fluid therapy and adjust oral fluid intake accordingly based on ongoing assessment of the client's hydration status.

c. Monitor pulse pressure every 6 hr: While monitoring pulse pressure can provide valuable information about fluid status and cardiac function, it may not be as specific or sensitive as other signs such as neck vein distention when assessing for fluid overload in clients receiving IV fluid replacement. Pulse pressure is the difference between the systolic and diastolic blood pressure readings and can be affected by various factors, including cardiac output, vascular resistance, and volume status. However, changes in pulse pressure may not always correlate directly with fluid overload, especially in clients with underlying cardiovascular conditions or receiving vasopressor medications. Therefore, more frequent and comprehensive assessments, including physical examination findings such as neck vein distention, are necessary to evaluate fluid balance accurately.

d. Limit oral fluids prior to bedtime: This option is incorrect because limiting oral fluids prior to bedtime is generally not indicated for dehydrated clients, especially those receiving IV fluid replacement. Restricting fluid intake may exacerbate dehydration and compromise the effectiveness of IV fluid therapy. Instead, the nurse should encourage adequate fluid intake throughout the day and evening to promote hydration and support the client's recovery from dehydration. Individualized fluid management strategies should be based on the client's fluid requirements, renal function, underlying condition, and response to therapy.

In summary, the correct answer is a because checking for neck vein distention is an essential intervention for monitoring fluid status and detecting potential complications such as fluid overload in clients receiving IV fluid replacement for dehydration. This assessment helps ensure safe and effective fluid management and prevents adverse outcomes associated with fluid overload.

A. Place the client in a negative airflow room. B. Obtain a throat culture after the initial dose of antibiotics. C. Implement droplet precautions. D. Place the client on a fluid restriction.

Correct Answer is C

Explanation

The correct answer is choice C. Implement droplet precautions. Streptococcal pharyngitis is a highly contagious infection caused by group A beta-hemolytic streptococcus. Droplet precautions are the appropriate precautionary measures to prevent the spread of the infection. This includes placing the client in a private room or with a client with the same infection, wearing a mask or respirator, and using proper hand hygiene. Option A is incorrect because negative airflow rooms are not required for clients with streptococcal pharyngitis. Option B is incorrect because throat cultures should be obtained before the initial dose of antibiotics. Option D is incorrect because fluid restriction is not a necessary intervention for clients with streptococcal pharyngitis.

Option A - Negative airflow rooms are used for airborne illnesses like tuberculosis.

Option B - Throat culture should be obtained before the initial dose of antibiotics.

Option D - Fluid restriction is not a necessary intervention for clients with streptococcal pharyngitis.

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A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy. Which of the following information should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A nurse is assisting in developing the plan of care for a client with streptococcal pharyngitis. What is an appropriate action to include in the plan of care?

Correct Answer is C

Explanation

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