HESI Case Study – Colonoscopy with Bowel Perforation
What assessment finding indicates to the nurse a need for additional assessment?
Stool has narrowed in diameter.
How should the nurse respond?
“It’s a recommended routine screen for colon cancer.”
Which foods should the nurse instruct the client to eat 24 hours prior to the procedure?
Jello and clear broth.
When instructing the client about the use of polyethylene glycol (GoLYTELY), what result should the nurse tell Mr. Jones to expect?
Frequent, watery stool.
Mr. Jones shares with the nurse that his friend who had the procedure complained of experiencing a lot of gas afterward. He asked what he can do to prevent this from happening to him.
Explain that this is a normal expectation following a colonoscopy.
Mr. Jones calls the clinic and states, “I can’t take anymore of the GoLYTELY. It tastes horrible.”
“Use ice to chill the medication.”
What information should the nurse give to Mr. Jones in response to his comment?
Have a significant other drive you back to your residence.
What action should the nurse take in response to the comment by Mr. Jones?
Notify the client’s HCP.
What action should the nurse take first?
Prime the tubing for the intravenous set.
Which action should the nurse take?
Continue to monitor the client.
What action should the nurse take immediately?
Administer flumazenil (Romazicon).
Which assessment finding should the nurse report to the surgeon before sending the client to the operating room?
Hemoglobin 9.1g/dL and hematocrit 30%
Which is the priority action for the nurse to take?
Place in a side-lying position.
How many milliliters should the nurse administer?
The client reports pain at the surgical site of 8 on a scale of 0-10. Which drug should the nurse administer.
Hydromorphone (Dilaudid) 2mg IV.
Thirty minutes after the analgesic adminstration, Mr. Jones indicates that his pain is 7. What action should the nurse take next? (select all that apply)
Contact the HCP for an additional prescription for pain medication.
Assess the client for surgical complications.
Which additional action(s) should the nurse take? (select all that apply)
Assure the client that the itchy feeling is a passing side effect.
Assess the skin for the presence of rash or hives.
Which laboratory result requires immediate action by the nurse?
Based on this finding, what should the nurse encourage Mr. Jones to do?
Use incentive spirometer.
Which assessment finding on the first post operative day requires further action by the nurse?
Heart rate is 124 beats per minute.
Which action should the nurse delegate to the UAP?
Take the 9:00 am vitals.
The nurse assesses Mr. Jones for potential complications that are common in clients on the first postoperative day. Which finding requires additional nursing action?
One calf 4cm larger than the other calf.
What action should the nurse take?
Provide an analgesic and reapproach the client 30 minutes after.
When assessing the client’s abdomen, which finding warrants action by the nurse?
Firm and tender with palpation.
What additional action should the nurse anticipate?
Maintain NPO status.
Which finding indicates that the client’s infection is improving?
The WBC count has decreased from 15,000mm to 11,000mm.
Which action should be of concern to the nurse when the nurse is providing discharge teaching for colostomy clients?
The client refuses to look at the colostomy site.
Which action best indicates to the nurse that the teaching regarding colostomy care has been effective?
The client successfully performs a return demonstration.
How should the nurse respond?
Open and manually deflate the bag.