Patient Assessment and Monitoring Flashcards

A patient on warfarin for atrial fibrillation is scheduled for a screening colonoscopy with possible polypectomy. When reviewing the pre-procedure labs, which result is most critical for the gastroenterology nurse to assess and report?

Answer: International Normalized Ratio (INR) of 2.8

The International Normalized Ratio (INR) measures the anticoagulant effect of warfarin. For a high-risk procedure like polypectomy, the INR must be within an acceptable range (typically <1.5) to minimize bleeding risk. An INR of 2.8 is therapeutic for atrial fibrillation but is too high for the procedure, indicating a significant bleeding risk that must be communicated to the provider.

Six hours after an ERCP, a patient complains of new-onset, severe, constant midepigastric pain that radiates to their back. The patient also reports nausea. Which of the following laboratory tests is the highest priority for the nurse to evaluate?

Answer: Serum amylase and lipase

The patient's symptoms are classic for acute pancreatitis, a well-known and serious complication of ERCP. Serum amylase and lipase are the primary biochemical markers used to diagnose acute pancreatitis, as these enzymes are released from the inflamed pancreas into the bloodstream.

During a colonoscopy, the nurse observes the patient suddenly become pale, diaphoretic, and bradycardic, with a blood pressure drop from 120/80 mmHg to 80/50 mmHg. What is the most likely cause of this clinical presentation?

Answer: Vasovagal response

This constellation of symptoms—pallor, diaphoresis (sweating), bradycardia, and hypotension—is the classic presentation of a vasovagal response. This response is often triggered during colonoscopy by visceral stimulation from scope insertion or insufflation, leading to overstimulation of the vagus nerve.

A nurse is using the modified Aldrete scoring system to assess a patient's readiness for discharge from the PACU. Which patient finding corresponds to the highest possible score (a score of 2) in the 'Activity' category?

Answer: Able to move all four extremities voluntarily or on command

The modified Aldrete scoring system assesses recovery from anesthesia across five categories: activity, respiration, circulation, consciousness, and oxygen saturation. In the 'Activity' category, a score of 2 is awarded when the patient can move all four extremities either voluntarily or on command, indicating a return of normal motor function.

A patient with an Automatic Implantable Cardioverter-Defibrillator (AICD) is scheduled for a colonoscopy where electrocautery will be used for a large polypectomy. Which nursing action is most critical to ensure patient safety?

Answer: Confirming that the device's antitachycardia functions have been disabled by a qualified professional.

Electromagnetic interference (EMI) from electrocautery can be misinterpreted by an AICD as a fatal arrhythmia, which could trigger an inappropriate and dangerous shock. Standard safety protocol requires that the device's antitachycardia functions be temporarily suspended or disabled before the procedure, typically by a cardiology or device specialist, and then re-enabled afterward.

When assessing a patient with a suspected colonic perforation, which physical examination finding is most indicative of peritonitis?

Answer: A rigid, board-like abdomen with rebound tenderness

Colonic perforation leads to the leakage of bowel contents into the sterile peritoneal cavity, causing inflammation known as peritonitis. The classic signs of peritonitis are a rigid, board-like abdomen due to involuntary muscle guarding, severe diffuse pain, and rebound tenderness. Bowel sounds are typically diminished or absent.