A nurse is providing instructions about bowel cleansing with polyethylene glycol-electrolyte solution (PEG) for a client who is going to have a colonoscopy. Which of the following information should the nurse include?

"Drink 400 ml every hour until bowel movements are clear"

"Expect bowel movements to begin 3 hr following completion of solution. "

"To prevent dehydration, drink an additional liter of fluid during preparation time. "

"Abdominal bloating might occur"

Answer and Explanation

The Correct Answer is D

Answer: D

Rationale:

A. "Drink 400 ml every hour until bowel movements are clear": The standard recommendation for PEG is to drink a specific volume, usually 240 ml every 10 to 15 minutes, rather than 400 ml every hour. The goal is to ensure the bowel is adequately cleansed, and this rate is typically more effective in achieving that.

B. "Expect bowel movements to begin 3 hr following completion of solution": Bowel movements often start within an hour or two after starting the PEG solution rather than waiting for 3 hours after finishing it. The timing can vary, but the onset is generally sooner.

C. "To prevent dehydration, drink an additional liter of fluid during preparation time": While it is important to stay hydrated, the specific recommendation for additional fluid intake beyond the PEG solution can vary. Typically, the instructions focus on the volume of PEG solution to drink rather than specifying a set amount of additional fluid.

D. "Abdominal bloating might occur": Abdominal bloating is a common side effect of bowel cleansing preparations like PEG. It can occur due to the large volume of fluid ingested and the rapid movement of the bowel contents, making it a relevant point to include in the instructions.

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Correct Answer is C

Explanation

A. Activate the fire alarm: While activating the fire alarm is important in alerting others to the fire, the priority is ensuring the safety of clients in the immediate vicinity. Moving clients away from the potential danger takes precedence over activating the alarm.
B. Use a fire extinguisher to put out the fire: While extinguishing the fire is necessary to prevent its spread, it should only be attempted after ensuring the safety of clients nearby. Attempting to use a fire extinguisher without first moving clients could put them at risk of injury or smoke inhalation.
C. Move any clients in the immediate vicinity: This is the priority action. Moving clients away from the potential danger of the smoldering fire helps protect them from smoke inhalation and potential burns. It ensures their safety while allowing the nurse to assess the situation and determine further actions.
D. Close the fire doors on the unit: Closing fire doors can help contain the fire and prevent its spread, but it is not the immediate priority when clients are in close proximity to the smoldering fire. Moving clients to safety should be the first action taken.

A. Provide reassurance to the client and parents. B. Perform a neurovascular assessment. C. Apply an ice pack to the casted leg D. Explain the discharge instructions to the client and parents.

Correct Answer is B

Explanation

A. Provide reassurance to the client and parents: While reassurance is important, it is not the priority action when caring for an adolescent client with a newly applied fiberglass cast for a fractured tibia. Ensuring adequate neurovascular status is critical to prevent complications associated with impaired circulation or nerve function.
B. Perform a neurovascular assessment: This is the correct action and the priority when caring for a client with a newly applied cast. The nurse should assess the client's neurovascular status by evaluating circulation, sensation, and movement distal to the casted limb. Changes in color, temperature, sensation, or movement could indicate impaired circulation or nerve function, which require immediate intervention to prevent complications such as compartment syndrome.
C. Apply an ice pack to the casted leg: While applying ice may help reduce swelling and discomfort, it is not the priority action when caring for a client with a newly applied cast. Additionally, applying ice directly to the cast may not effectively reach the skin and underlying tissues, potentially causing discomfort without providing significant benefit.
D. Explain the discharge instructions to the client and parents: Providing discharge instructions is important for client education, but it is not the priority action immediately after applying a cast. Ensuring the client's safety and well-being by performing a neurovascular assessment takes precedence to identify and address any potential complications associated with the cast.

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A nurse is providing instructions about bowel cleansing with polyethylene glycol-electrolyte solution (PEG) for a client who is going to have a colonoscopy. Which of the following information should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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