A nurse in an urgent care facility is collecting data from a client who was stung by a wasp. Which of the following findings indicates the client is experiencing anaphylaxis?

The correct answer is Choice A.

Choice A rationale: A clear liquid diet 1 to 3 days before a colonoscopy minimizes residue in the colon, enhancing mucosal visualization and reducing the risk of missed lesions. Clear liquids include water, broth, tea, and gelatin, which are easily absorbed and leave minimal waste. This dietary preparation complements bowel cleansing agents like polyethylene glycol. Inadequate preparation can obscure polyps or inflammation. Normal stool consistency should be absent during the procedure to ensure optimal diagnostic accuracy.

Choice B rationale: Polypectomy is typically performed during the colonoscopy itself if polyps are detected. Most polyps are removed using snares or biopsy forceps during the same session, reducing the need for a second procedure. Scheduling another procedure is reserved for complex or large lesions requiring advanced techniques. Delaying removal increases the risk of progression to malignancy. Normal colonoscopy findings include pink mucosa and absence of polyps; any deviation warrants immediate intervention when feasible.

Choice C rationale: Restricting intake to only water for 12 hours before the procedure is insufficient and potentially misleading. Colonoscopy preparation requires both dietary modification and pharmacologic bowel cleansing, not just fasting. Water alone does not clear the colon of fecal matter. Additionally, fasting without electrolyte replacement may lead to dehydration and electrolyte imbalance. Normal serum potassium ranges from 3.5 to 5.0 mEq/L; inadequate preparation may cause hypokalemia, especially with laxative use.

Choice D rationale: Enemas are not routinely recommended 2 days before colonoscopy. They may be used adjunctively on the day of the procedure for distal colon cleansing but are insufficient for full bowel preparation. Oral bowel prep agents like polyethylene glycol are preferred for complete evacuation. Enemas only reach the rectosigmoid region and do not cleanse the ascending or transverse colon. Incomplete prep compromises mucosal visualization and diagnostic yield, increasing false-negative rates.

The correct answer is choice C: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.

Choice C rationale: A significant drop in blood pressure can indicate various serious conditions, such as shock, hemorrhage, or a severe infection. The nurse should assess the client further and intervene as necessary to prevent complications.

Choice A rationale: The change in temperature may indicate the onset of a fever and requires further assessment, but it is not as immediately concerning as the sudden drop in blood pressure.

Choice B rationale: The change in respiratory rate could be a result of factors like pain, anxiety, or exercise. While it warrants further assessment, it is not as critical as the blood pressure change.

Choice D rationale: The heart rate change may be a response to medications, rest, or other factors. It should be monitored and assessed, but the priority finding is the blood pressure change, which may indicate a more severe underlying issue.