A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take in preparation for the procedure?
Shave the client from axillae to groin.
Administer a cleansing enema.
Have the client drink contrast medium.
Ensure the signed consent is in the medical record.
The Correct Answer is D
Choice A reason: Shaving the client from axillae to groin is not necessary, as it has no relation to the procedure and can cause skin irritation or infection.
Choice B reason: Administering a cleansing enema is not required, as it does not affect the upper gastrointestinal tract that is examined by the procedure. The client should fast for at least 6 hours before the procedure to ensure an empty stomach.
Choice C reason: Having the client drink contrast medium is not indicated, as it can interfere with the visualization of the mucosa and lesions by the endoscope. The client may receive a local anesthetic spray or gargle to numb the throat and a sedative to relax and reduce discomfort during the procedure.
Choice D reason: Ensuring the signed consent is in the medical record is an essential action, as it indicates that the client has been informed about the purpose, risks, benefits, and alternatives of the procedure and has agreed to undergo it voluntarily.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Performing breast exams every other month is not an adequate frequency, as it can delay the detection of any changes or abnormalities. The client should perform breast exams monthly, preferably a few days after their period ends.
Choice B reason: Having one breast larger than the other is a common variation and not a cause for concern, unless there is a sudden change in size or shape. The client should be aware of their normal breast appearance and report any changes to their provider.
Choice C reason: Performing breast exams the day their period begins is not an optimal time, as their breasts may be swollen, tender, or lumpy due to hormonal fluctuations. The client should perform breast exams when their breasts are not affected by their menstrual cycle, such as a week after their period ends.
Choice D reason: Having skin dimpling on their breasts is not a common variation and may indicate an underlying tumor that pulls on the connective tissue and causes puckering of the skin. The client should inspect their breasts for any changes in skin texture, such as dimpling, peau d'orange, or redness, and report them to their provider.
Correct Answer is A
Explanation
Choice A reason: Changed mental status, such as confusion, agitation, or delirium, can be a sign of a bladder infection in older adults, as they may not have the typical symptoms of dysuria, frequency, or urgency.
Choice B reason: WBC count 9,000/mm³ is within the normal range of 4,500 to 11,000/mm³ and does not indicate an infection.
Choice C reason: Diminished reflexes are not related to a bladder infection and may be due to aging, neurological disorders, or medication side effects.
Choice D reason: Temperature 37.3°C (99.1°F) is slightly elevated but not indicative of a bladder infection. Older adults may have lower baseline temperatures and may not develop fever in response to an infection.
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