nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should thenurse make?

“You may feel some cramping during the procedure.”

“Don’t worry, you won’t remember anything about the procedure due to the effects of the medication.”

“Most clients report more discomfort from the preparation than from the procedure itself.”

“You shouldn’t feel any pain since the local area is anesthetized.”

Answer and Explanation

The Correct Answer is A

A. “You may feel some cramping during the procedure.” - This response provides an honest and accurate expectation of potential discomfort during the colonoscopy.

B. “Don’t worry, you won’t remember anything about the procedure due to the effects of the medication.” - Sedation may help with recall, but it doesn't eliminate the possibility of feeling discomfort.

C. “Most clients report more discomfort from the preparation than from the procedure itself.” - While this statement is generally true, it doesn't directly address the client's concern about pain during the colonoscopy.

D. “You shouldn’t feel any pain since the local area is anesthetized.” - Colonoscopy is typically done with conscious sedation rather than local anesthesia, and some discomfort may still be felt.

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Correct Answer is A

Explanation

a. Ineffective airway clearance: This is the priority as it addresses the immediate threat to the client's respiratory status. Accumulation of thick, copious secretions can lead to airway

obstruction and respiratory distress.

b. Malnourishment: While important, addressing malnourishment is not an immediate

postoperative priority. The client may receive nutrition through alternative means until normal swallowing function is restored.

c. High risk for infection: Infection is a concern, but ensuring airway clearance takes precedence in the immediate postoperative period.

d. Impaired verbal communication: Verbal communication is important, but it is not as immediate a concern as ensuring the airway is clear to prevent respiratory compromise.

A. Position the client on the nonoperative side. B. Monitor respiratory status every 8 hr. C. Elevate the head of the bed to a 15° angle. D. Encourage the client to splint the incision when coughing.

Correct Answer is D

Explanation

a. Position the client on the nonoperative side: The client should be positioned on the operative side to facilitate expansion of the remaining lung.

b. Monitor respiratory status every 8 hr: Postoperative respiratory status should be monitored more frequently than every 8 hours to assess for complications, especially in the initial

postoperative period.

c. Elevate the head of the bed to a 15° angle: The head of the bed should be elevated to a higher angle (usually 30-45 degrees) to promote optimal lung expansion and reduce the risk of

complications such as atelectasis.

d. Encourage the client to splint the incision when coughing: Encouraging the client to splint the incision when coughing helps minimize pain and supports effective coughing to prevent

complications such as atelectasis.

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nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should thenurse make?

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