HESI Case Study - Colonoscopy with
Bowel Perforation (Answered)
What assessment finding indicates to the nurse a need for additional
assessment?
Stool has narrowed in diameter.
How should the nurse respond?
"It's a recommended routine screen for colon cancer."
Which foods should the nurse instruct the client to eat 24 hours prior to the
procedure?
Jello and clear broth.
When instructing the client about the use of polyethylene glycol (GoLYTELY),
what result should the nurse tell Mr. Jones to expect?
Frequent, watery stool.
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.
Explain that this is a normal expectation following a colonoscopy.
Mr. Jones calls the clinic and states, "I can't take anymore of the GoLYTELY. It
tastes horrible."
"Use ice to chill the medication."
What information should the nurse give to Mr. Jones in response to his
comment?
Have a significant other drive you back to your residence.
What action should the nurse take in response to the comment by Mr. Jones?
Notify the client's HCP.
What action should the nurse take first?
Prime the tubing for the intravenous set.
Which action should the nurse take?
Continue to monitor the client.
What action should the nurse take immediately?
Administer flumazenil (Romazicon).
Which assessment finding should the nurse report to the surgeon before sending
the client to the operating room?
Hemoglobin 9.1g/dL and hematocrit 30%
Which is the priority action for the nurse to take?
Place in a side-lying position.
How many milliliters should the nurse administer?
2
The client reports pain at the surgical site of 8 on a scale of 0-10. Which drug
should the nurse administer.
Hydromorphone (Dilaudid) 2mg IV.
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)
Bowel Perforation (Answered)
What assessment finding indicates to the nurse a need for additional
assessment?
Stool has narrowed in diameter.
How should the nurse respond?
"It's a recommended routine screen for colon cancer."
Which foods should the nurse instruct the client to eat 24 hours prior to the
procedure?
Jello and clear broth.
When instructing the client about the use of polyethylene glycol (GoLYTELY),
what result should the nurse tell Mr. Jones to expect?
Frequent, watery stool.
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.
Explain that this is a normal expectation following a colonoscopy.
Mr. Jones calls the clinic and states, "I can't take anymore of the GoLYTELY. It
tastes horrible."
"Use ice to chill the medication."
What information should the nurse give to Mr. Jones in response to his
comment?
Have a significant other drive you back to your residence.
What action should the nurse take in response to the comment by Mr. Jones?
Notify the client's HCP.
What action should the nurse take first?
Prime the tubing for the intravenous set.
Which action should the nurse take?
Continue to monitor the client.
What action should the nurse take immediately?
Administer flumazenil (Romazicon).
Which assessment finding should the nurse report to the surgeon before sending
the client to the operating room?
Hemoglobin 9.1g/dL and hematocrit 30%
Which is the priority action for the nurse to take?
Place in a side-lying position.
How many milliliters should the nurse administer?
2
The client reports pain at the surgical site of 8 on a scale of 0-10. Which drug
should the nurse administer.
Hydromorphone (Dilaudid) 2mg IV.
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)
