NU371 Week 6 HESI Case Study: Colonoscopy with Bowel Perforation - 28 Questions with Certified Answers

NU371 Week 6 HESI Case Study: Colonoscopy with Bowel Perforation - 28 Questions with Certified Answers A client with a family history of colon cancer presents to the clinic for his annual physical. The nurse interviews the client regarding his elimination patterns. What client information indicates to the nurse a need for additional assessment? o Increased flatulence. o Bowel movement every other day. o Blood on paper when constipated. o Change in bowel habits. o Change in bowel habits. · A change in bowel habits is one of the 7 warning signs of cancer. How should the nurse respond? o Explain that a colonoscopy is a recommended routine screening for colon cancer. o Tell the client that a colonoscopy is used to determine the existence of Crohn's disease. o Remind the client that the HCP ordered the procedure. o Inform the client that a colonoscopy is needed to evaluate preexisting hemorrhoids. o Explain that a colonoscopy is a recommended routine screening for colon cancer. · The American Cancer Society recommends a colonoscopy every 10 years, starting at age 50, for everyone at average risk to screen for colorectal cancer. Some individuals may require earlier or more frequent screenings depending on their personal risk factors. The primary healthcare provider (HCP) prescribes a screening colonoscopy. The client asks the nurse, why he needs a colonoscopy if he feels fine. The nurse provides preparatory teaching for the prescribed colonoscopy. It includes dietary restrictions, bowel preparation, and procedural expectations. Which foods should the nurse instruct the client to eat 24 hours prior to the procedure? o Whole grain toast and yogurt. o Fresh apple and raw broccoli. o Jello and clear broth. o Roast beef and scrambled eggs. o Jello and clear broth. · The client should consume clear liquids 24 hours before the procedure to have a clear colon to aid visualization. Two liters of polyethylene glycol solution is prescribed for the client to consume the day before the procedure. When instructing the client about the use of polyethylene glycol, what result should the nurse tell the client to expect? o Frequent, watery stool. o Black, tarry feces. o Gastric reflux. o Metallic taste in mouth. o Frequent, watery stool. · Polyethylene glycol is a saline and osmotic laxative solution that causes retention of fluid in the intestinal lumen from the osmotic effect. Its purpose is to clean out all feces from the colon. By the end of the preparation, most clients are expelling almost clear, watery stool. The client shares with the nurse that his friend who had the procedure complained of experiencing a lot of gas afterwards. He asks what he can do to prevent this from happening to him. How should the nurse respond? o Reassure him that everyone has gas and that no one thinks anything of it. o Explain that this is a normal expectation following a colonoscopy. o Emphasize the importance of adequate bowel preparation to prevent it. o Suggest that his friend must have experienced a minor complication. o Explain that this is a normal expectation following a colonoscopy. · The gas experienced by the client following a colonoscopy is largely due to air that is pumped into the colon during the procedure. The gas should be expelled normally to prevent painful distention. The client calls the clinic and tells them he can't take any more of the polyethylene glycol because it tastes horrible. The nurse instructs the client that all of the polyethylene glycol needs to be taken and suggests icing the solution to make it more palatable to ingest. Ice may also numb the taste buds while drinking the very cold solution. The nurse gives the client the location of the center for the procedure. The client tells the nurse that since it is near his home, he will walk there and back. What instruction should the nurse give to the client in response to his comment? o Take a bus home when the procedure is finished. o Driving to the clinic and back home is a better option. o Arrange for a taxi to take you back to your house. o Have a significant other drive you back to your residence. o Have a significant other drive you back to your residence. · Because residual effects from the sedation and/or weakness from the procedure preparation can be present, a client should be discharged with a responsible adult. The client presents at the center the following morning for the colonoscopy procedure. The client tells the nurse that he is still not sure why I need this test and that is sounds risky. What action should the nurse take in response to the comment by the client? o Explain the risks and benefits. o Request that the client sign the consent form. o Notify the client's HCP. o Reassure the client that the procedure is safe. o Notify the client's HCP. · The HCP performing the procedure should be notified to answer the client's questions prior to the procedure. After the HCP is notified and answers the client's questions, the client signs the consent form. The nurse proceeds to establish intravenous (IV) access. Which action should the nurse take first? o Verify the prescription to be infused. o Choose a site for the placement of the catheter. o Apply the tourniquet 4 inches above the site. o Prep the skin over the IV site selected with approved antiseptic. o Verify the prescription to be infused. · Knowing what will be infusing will determine what size catheter and it's best location. The client is prepared, and procedural sedation anesthesia is established with morphine and midazolam. The client has ptosis and speaks in a slurred voice. Which action should the nurse take? o Administer naloxone. o Apply oxygen per mask. o Continue to monitor the client. o Perform sternal rub. o Continue to monitor the client. · Because ptosis, or droopy eyelids, and slurred speech are signs of the desired level of sedation for a client during the procedure, the nurse should continue to monitor the client. The colonoscopy is completed, but 30 minutes after the procedure, the client cannot be aroused. What action should the nurse take immediately? o Administer flumazenil. o Induce a noxious stimuli. o Administer oxygen via a non-breathing mask at 15 L/minute. o Infuse bolus 500 mL sodium chloride 0.9%. o Administer flumazenil. · Respiratory depression can occur in a client after a procedure requiring sedation. If the client cannot be aroused, the sedation drugs should be reversed. Flumazenil reverses the effects of benzodiazepines and naloxone for narcotics. Which assessment finding should the nurse report to the surgeon before sending the client to the operating room? o Hemoglobin 9.1 g/dL (91 g/L). o Potassium 3.5 mEq/L (3.5 mmol/L). o Oral temperature 99o F (37.2o C). o Pulse oximeter 95% on room air. o Hemoglobin 9.1 g/dL (91 g/L). · Surgical procedures with general anesthesia normally require a hemoglobin of 10.0 g/dL (100 g/L) or higher in order to ensure adequate oxygen-carrying capacity. The surgeon should be notified because the client may need to be transfused before or during the surgery. The client is given blood during the procedure, and the surgery to establish a temporary double-barrel colostomy is successful. After discharge from the postanesthesia care unit, the client is transported to the postoperative care unit. During the admission assessment to the unit, the client reports feeling nauseated and gags. Which is the priority action for the nurse to take? o Administer a PRN antiemetic. o Apply a cold washcloth to face. o Provide an emesis basin. o Place in a side-lying position. o Place in a side-lying position. · Placing the client in the "rescuer" position is the priority action in order to prevent aspiration in case of emesis. Aspiration of gastric contents into the lungs can cause airway obstruction, laryngospasm, infection, and/or pulmonary edema. The postoperative prescriptions include hydromorphone 2 mg IV every 4 to 6 hours PRN for pain, hydrocodone/acetaminophen 1 to 2 tablets PO every 4 hours PRN for pain, metoclopramide 10 to 20 mg IV every 4 to 6 hours PRN for nausea. When the client starts to vomit, the nurse decides to administer 10 mg IV metoclopramide. Metoclopramide is supplied as 5 mg/mL per ampule. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is necessary, round to the whole number.) o 2 The client reports pain at the surgical site of 8 on a scale of 0-10. Which drug should the nurse administer? o Hydromorphone 2 mg IV. o Hydromorphone 2 mg IM every 4 to 6 hours. o Hydrocodone/acetaminophen 1 tablet PO. o Hydrocodone/acetaminophen 2 tablets PO. o Hydromorphone 2 mg IV. · Because the client is postoperative and experiencing severe pain, he should be given the hydromorphone. With the already noted nausea, PO route should not be considered. 30 minutes after the analgesic administration, client indicates his pain is 7. What action should the nurse take next? Select all that apply. o Tell the client that another dose can be given in 3½ hours. o Contact the HCP for an additional prescription for pain medication. o Administer 2 mg hydromorphone. o Assist the client in guided imagery, a relaxation technique. o Assess the client's surgical abdominal incisions and abdomen. o Contact the HCP for an additional prescription for pain medication. · The client was given hydromorphone 2 mg as prescribed. The medication was not effective in relieving the pain. o Assess the client's surgical abdominal incisions and abdomen. · Uncontrolled pain can be a precursor of postoperative complications; therefore, to ensure the client's safety, it is important for the nurse to reassess the client after the initial dose of the pain medication is given. The HCP orders an additional dose of hydromorphone of 2 mg IV. The nurse provides an additional 2 mg hydromorphone. An hour later the client is no longer in pain, but the nurse notices that the client is scratching his arms and chest. The nurse administers the PRN prescribed antihistamine. Which additional action(s) should the nurse take? Select all that apply. o Apply a moisturizing lotion to the skin. o Assure the client that the itching is a passing side effect. o Complete an adverse drug reaction form. o Obtain a prescription for ondansetron hydrochloride (Zofran). o Assess the skin for the presence of a rash or hives. o Assure the client that the itching is a passing side effect. · Pruritus (itching) is a possible, temporary, common side effect to narcotics, especially if the client is opiate-naïve. o Assess the skin for the presence of a rash or hives. · The nurse should ensure that the itching is associated with a common side effect. On the first day after surgery, the nurse reviews the client laboratory results and prepares for the morning assessment. Which laboratory result requires immediate action by the nurse? o Glucose 147 mg/dL (8.16 mmol/L). o Potassium 3.0 mEq/L (3.0 mmol/L). o Blood urea nitrogen (BUN) 27 mg/dL. o Hemoglobin 10.1 g/dL (101 g/L). o Potassium 3.0 mEq/L (3.0 mmol/L). · Potassium is an intracellular electrolyte, so a serum decrease reflects significant deficiency. Adequate potassium is essential for muscular contraction, particularly cardiac muscles. The kidneys excrete most of potassium and will not be able to retain enough potassium to correct this deficiency. Because of the client's vomiting, replacement of potassium will be required. Normal value 3.5–5.0 mEq/L (3.5–5.0 mmol/L). After informing the healthcare provider about the client's decrease in serum potassium and receiving a prescription for potassium chloride (KCl) supplement, the nurse assesses the client. He has crackles at the base of the bilateral lung fields. Based on this finding, what should the nurse encourage the client to do? o Use incentive spirometer. o Pursed-lip breathing. o Hallway ambulation. o Increase fluids. o Use incentive spirometer. · Atelectasis (collapsed, airless alveoli) is a common postoperative risk due to anesthesia, restricted breathing from the pain, and retained secretions. Crackles will typically resolve by deep breathing promoted by the use of an incentive spirometer. Which assessment finding on the first postoperative day requires further action by the nurse? o No bowel sounds are auscultated. o Stoma oozes blood when touched. o Heart rate is 124 beats per minute. o Oral temperature is 100° F (37.8° C). o Heart rate is 124 beats per minute. · Tachycardia can be an early sign of many complications, including dehydration, fever, infection, and/or shock. This symptom must be further assessed. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? o Take the 9:00 a.m. vital signs. o Change the colostomy bag. o Evaluate pain. o Teach splinting before coughing. o Take the 9:00 a.m. vital signs. · The UAP can obtain data, including vital signs. The nurse will retain the responsibility to interpret that data to determine if the vital signs are within normal ranges. The nurse assesses the client for potential complications that are common in clients on the first postoperative day. Which finding requires additional nursing action? o Mucus in the colostomy drainage apparatus. o 1+ pitting edema in the lower extremities. o One calf 4 cm larger than the other calf. o Erythema around the surgical site. o One calf 4 cm larger than the other calf. · Unilateral swelling in a lower extremity is one of the most common symptoms of a deep vein thrombosis (DVT). Following major abdominal surgery, a client is at risk for a blood clot due to immobility, manipulation of vessels, and hypercoagulability. The client refuses to use the prescribed incentive spirometer because of his operative pain. What action should the nurse take? o Reinforce that its use is very important. o Allow the client autonomy and respect his wishes. o Explain that it is prescribed for every surgical client. o Provide an analgesic and reapproach the client 30 minutes later. o Provide an analgesic and approach the client 30 minutes later. · Providing pain relief and then approaching the client when the client is more comfortable is most likely to produce the best client receptiveness. When assessing the client's abdomen, which finding warrants action by the nurse? o Stoma site appears swollen. o Firm and tender with palpation. o Tympanic upon auscultation. o Negative rebound tenderness. o Firm and tender with palpation. · This could indicate peritoneal irritation from many complications. Because the abdomen should be soft and non-tender with palpation, this finding requires further action by the nurse. The nurse notifies the HCP, who prescribes laboratory work and a broad-spectrum intravenous antibiotic. What additional action should the nurse anticipate? o Maintain NPO status. o Obtain sputum culture. o Check creatinine level. o Irrigate colostomy. o Maintain NPO status. · The client has a potential "surgical abdomen" and should be given nothing by mouth in case an emergency operation is needed. Which finding indicates that the client's infection is improving? o The antibiotic's peak and trough levels are within the therapeutic range. o The urine specific gravity is 1.020. o The WBC count has decreased from 15,000 to 11,000 /μL (15 to 11 x 109/L). o The client reports that his pain level is 5. o The WBC count has decreased from 15,000 to 11,000 /μL (15 to 11 x 109/L). · The white blood cells (indicative of infection) are decreasing towards the normal range of 5000–10,000/μL (5–10 × 109/L). This is indicative of an improving trend. Which action should be of concern to the nurse when the nurse is providing discharge teaching for colostomy clients? o The client asks if the bag can be seen through clothing. o The client expresses fear that the bag will have odors. o The client refuses to look at the colostomy site. o The client requests help with changing the colostomy bag. o The client refuses to look at the colostomy site. · It can indicate lack of acceptance to the change in body image and a lack of willingness to deal with the new condition. A lot of education is needed and engagement is imperative. The nurse provides teaching for the client in preparation for the client's discharge. Which action best indicates to the nurse that the teaching regarding colostomy care has been effective? o The client verbalizes that he understands how to care for the colostomy. o The client reads the provided brochures on colostomy care. o The client successfully performs a return demonstration. o The client watches a video showing step-by-step directions. o The client successfully performs a return demonstration. · By successfully performing a return demonstration, such as emptying a colostomy bag, the client demonstrates to the nurse that the teaching has been effective. The client notes that his colostomy bag is inflated with air and asks the nurse what he should do. How should the nurse respond? o Put pin pricks in the bag to release air. o Open and manually deflate the bag. o Change the colostomy bag. o Put an antiflatulent tablet in the bag. o Open and manually deflate the bag. · The client is passing gas, or flatus. Since colostomy bags are expensive, manually removing the air is the cost-effective way to handle this normal finding.