A nurse is planning care for a client who requires screening for rectal cancer.
Which of the following tests should the nurse anticipate in the client's care?
Colonoscopy.
Endoscopic retrograde cholangiopancreatography (ERCP).
Upper GI series.
Upper GI endoscopy.
The Correct Answer is A
Choice A rationale
Colonoscopy is the recommended test for screening for rectal cancer. It allows for direct visualization of the entire colon and rectum, enabling the detection and biopsy of polyps or
suspicious lesions. It is the gold standard for colorectal cancer screening.
Choice B rationale
Endoscopic retrograde cholangiopancreatography (ERCP) is used to diagnose and treat conditions of the bile ducts, pancreas, and gallbladder. It’s not typically used for colorectal
cancer screening.
Choice C rationale
An upper GI series involves X-rays of the upper gastrointestinal tract (esophagus, stomach, and duodenum) after swallowing a contrast medium. This test does not visualize the
lower GI tract, including the colon and rectum, and is therefore not suitable for rectal cancer screening.
Choice D rationale
Upper GI endoscopy allows for direct visualization of the upper gastrointestinal tract but does not reach the colon and rectum. Hence, it is not used for screening rectal cancer
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Correct Answer is D
Explanation
Choice A rationale
Blood in the urine (hematuria) is not a typical finding in urinary retention. It may indicate other conditions such as infection, stones, or malignancy.
Choice B rationale
Cloudy urine is often a sign of infection, not typically associated with urinary retention. It can be caused by the presence of bacteria, white blood cells, or crystals.
Choice C rationale
Dark-colored urine can result from dehydration or certain foods and medications. It is not a specific finding of urinary retention.
Choice D rationale
Leakage of urine, also known as overflow incontinence, can occur in urinary retention. This happens when the bladder becomes overly full, and small amounts of urine leak out due to the pressure.
Correct Answer is B
Explanation
Choice A rationale
Placing the client into a right lateral position is not the standard position for administering an enema. The left lateral (Sims') position is commonly used as it facilitates the flow of the
solution into the colon.
Choice B rationale
Warming the enema solution to room temperature helps ensure the client's comfort and can prevent cramping and discomfort. Cold solutions can cause discomfort and cramping,
making the procedure less tolerable for the client.
Choice C rationale
Sterile technique is not required for administering an enema. Clean technique is generally sufficient unless otherwise indicated by the client’s condition or specific medical orders.
Choice D rationale
Lubricating the tubing is essential to ensure smooth insertion and prevent trauma to the rectal mucosa, but an oil-based lubricant is not typically used as it can interfere with the
absorption of the enema solution. Water-soluble lubricants are preferred.