A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in 1 week. Which of the following client statements indicates an understanding of the teaching?
"I will follow a full-liquid diet the day before the procedure."
"I'll have my friend drive me home after the procedure."
"I can expect rectal bleeding for a week after the procedure”
"This procedure will take place while I’m under general anesthesia.”
The Correct Answer is B
Rationale:
A. "I will follow a full-liquid diet the day before the procedure.": Clients are typically instructed to follow a clear-liquid, not full-liquid, diet the day before a colonoscopy. Clear liquids like broth, gelatin, and clear juice help ensure the colon is clean for optimal visualization.
B. "I'll have my friend drive me home after the procedure.": Sedation is usually administered during a colonoscopy, which impairs alertness and coordination. Having a responsible adult to drive the client home is necessary and reflects appropriate understanding of post-procedure safety.
C. "I can expect rectal bleeding for a week after the procedure”: Rectal bleeding after a colonoscopy is not expected and could indicate complications such as a perforation or polyp removal site bleeding. Any persistent or heavy bleeding should be reported immediately.
D. "This procedure will take place while I’m under general anesthesia.”: Colonoscopies are generally performed under moderate (conscious) sedation, not general anesthesia. Clients remain semi-awake but relaxed and unaware, making this statement inaccurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
• Temperature: An elevated temperature of 39.3° C is consistent with an active infection like pneumonia. This finding supports the need for antibiotic treatment and does not delay administration unless linked to an adverse drug reaction.
• WBC count: A WBC count of 16,000/mm³ indicates leukocytosis, which is expected in bacterial pneumonia. It confirms infection and the need for antibiotics, not a reason to withhold cefazolin.
• Allergies: The client has a documented allergy to penicillin, which is critical because cefazolin is a cephalosporin. Cephalosporins share a similar beta-lactam structure and can cross-react in clients with penicillin allergies, increasing the risk of anaphylaxis. Reporting this ensures safe prescribing and prevents a life-threatening hypersensitivity reaction.
• Chest x-ray: The left lower lobe density confirms pneumonia. This imaging supports the clinical decision to administer antibiotics and does not warrant withholding the prescribed medication.
Correct Answer is A
Explanation
Rationale:
A. Support the extremity above and below each joint during the exercises: Supporting the limb properly prevents strain on the joints and muscles, reduces pain, and helps maintain proper alignment during passive range-of-motion exercises.
B. Repeat each exercise movement 10 times: Repetitions vary depending on the client’s condition and tolerance. A general guideline is 5 to 10 repetitions, but individualized assessment is important to avoid fatigue or injury.
C. Move each joint just past the point of resistance: Moving a joint beyond the point of resistance can cause pain, injury, or dislocation. Movements should be gentle and stop when resistance or discomfort is felt.
D. Position the bed at mid-thigh level: Bed height should be adjusted for caregiver ergonomics to prevent injury, but "mid-thigh level" is not a standard recommendation for performing range-of-motion exercises.
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