Question 1

Which nursing intervention is essential for a client following an upper gastrointestinal endoscopy?&#10;A)Assessment of the pedal pulses&#10;B)Assessment of the gag reflex&#10;C)Monitoring for blood pressure&#10;D)Assessment of the respiratory rate

Accepted Answer

After the upper gastrointestinal endoscopy, the client must remain in NPO until the gag reflex returns. Gag reflex usually returns in 1 to 2 hours.

Question 2

A nurse is caring for a client who was ordered to receive an enema before a colonoscopy. Which of the following is the least important to determine before performing the procedure:&#10;A)Assess whether the client has sphincter control.&#10;B)Assess whether the client can tolerate sitting up.&#10;C)Assess if the client can tolerate a left lateral position.&#10;D)Assess the abdomen.

Accepted Answer

Whether the client can tolerate sitting up or ambulating is unnecessary. The client can use a bedpan to manage elimination needs or remain in bed if he or she cannot tolerate walking or remaining upright. It is important to assess the client's sphincter control. If the client does not have sphincter control, the nurse must properly position the client in supine position on the bed with a bedpan. Option C is correct; left lateral position is the most preferable position because it allows the flow of solution by gravity into the sigmoid and descending colon.

Question 3

A client with acute pancreatitis is complaining of severe abdominal pain. The nurse should teach the client to avoid which of the following positions to alleviate the pain?&#10;A)Lying supine in the bed&#10;B)Flexing the left leg&#10;C)Sitting up in the bed&#10;D)Leaning forward

Accepted Answer

Lying supine in bed and walking can aggravate the pain associated with acute pancreatitis. Therefore, these positions must be avoided. Flexing the legs, sitting up, and leaning forward can alleviate the pain.

Question 4

The nurse places the client in this position immediately after a percutaneous liver biopsy:&#10;A)Semi-Fowler's position&#10;B)Left-side lying position&#10;C)Right-side lying position&#10;D)Supine position.

Accepted Answer

Placing the client on the right side applies pressure to the site of biopsy, preventing bleeding. The liver is located on the right upper side of the abdomen. The other options are not appropriate for a post-percutaneous liver biopsy client.

Question 5

A client with a perforated bowel is scheduled for emergency surgery. The nurse finds out that the client could not sign the consent form due to sedation induced by the administration of narcotic analgesics. The nurse's most appropriate action is to:

A)Call the client's family to obtain consent, and have it witnessed by two individuals
B)Give the consent herself, and ask two individuals to be the witnesses
C)Send the client to surgery without an informed consent
D)Ask the physician to sign the consent and stand as one of the witnesses

Accepted Answer

If the client is not able to sign an informed consent, the nurse must make every effort to obtain consent from a family member. A telephone call is acceptable as long as the consent is witnessed by at least 2 individuals, who can hear the oral consent. In emergency situations, if the client is unable to sign and no family member is available, the surgery can be performed without consent. These policies may vary by state and facility.

Deck 2: Basic Care