HESI Case Study – Colonoscopy with Bowel Perforation – Flashcards
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What assessment finding indicates to the nurse a need for additional assessment?
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Stool has narrowed in diameter.
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How should the nurse respond?
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"It's a recommended routine screen for colon cancer."
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Which foods should the nurse instruct the client to eat 24 hours prior to the procedure?
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Jello and clear broth.
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When instructing the client about the use of polyethylene glycol (GoLYTELY), what result should the nurse tell Mr. Jones to expect?
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Frequent, watery stool.
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Mr. Jones shares with the nurse that his friend who had the procedure complained of experiencing a lot of gas afterward. He asked what he can do to prevent this from happening to him.
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Explain that this is a normal expectation following a colonoscopy.
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Mr. Jones calls the clinic and states, "I can't take anymore of the GoLYTELY. It tastes horrible."
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"Use ice to chill the medication."
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What information should the nurse give to Mr. Jones in response to his comment?
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Have a significant other drive you back to your residence.
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What action should the nurse take in response to the comment by Mr. Jones?
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Notify the client's HCP.
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What action should the nurse take first?
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Prime the tubing for the intravenous set.
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Which action should the nurse take?
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Continue to monitor the client.
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What action should the nurse take immediately?
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Administer flumazenil (Romazicon).
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Which assessment finding should the nurse report to the surgeon before sending the client to the operating room?
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Hemoglobin 9.1g/dL and hematocrit 30%
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Which is the priority action for the nurse to take?
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Place in a side-lying position.
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How many milliliters should the nurse administer?
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2
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The client reports pain at the surgical site of 8 on a scale of 0-10. Which drug should the nurse administer.
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Hydromorphone (Dilaudid) 2mg IV.
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Thirty minutes after the analgesic adminstration, Mr. Jones indicates that his pain is 7. What action should the nurse take next? (select all that apply)
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Contact the HCP for an additional prescription for pain medication. Assess the client for surgical complications.
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Which additional action(s) should the nurse take? (select all that apply)
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Assure the client that the itchy feeling is a passing side effect. Assess the skin for the presence of rash or hives.
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Which laboratory result requires immediate action by the nurse?
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Potassium 3.0mEq/dL.
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Based on this finding, what should the nurse encourage Mr. Jones to do?
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Use incentive spirometer.
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Which assessment finding on the first post operative day requires further action by the nurse?
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Heart rate is 124 beats per minute.
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Which action should the nurse delegate to the UAP?
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Take the 9:00 am vitals.
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The nurse assesses Mr. Jones for potential complications that are common in clients on the first postoperative day. Which finding requires additional nursing action?
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One calf 4cm larger than the other calf.
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What action should the nurse take?
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Provide an analgesic and reapproach the client 30 minutes after.
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When assessing the client's abdomen, which finding warrants action by the nurse?
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Firm and tender with palpation.
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What additional action should the nurse anticipate?
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Maintain NPO status.
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Which finding indicates that the client's infection is improving?
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The WBC count has decreased from 15,000mm to 11,000mm.
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Which action should be of concern to the nurse when the nurse is providing discharge teaching for colostomy clients?
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The client refuses to look at the colostomy site.
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Which action best indicates to the nurse that the teaching regarding colostomy care has been effective?
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The client successfully performs a return demonstration.
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How should the nurse respond?
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Open and manually deflate the bag.
