A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis?
Imbalanced nutrition: Less than body requirements related to decreased oral intake
Risk for infection related to possible rupture of appendix
Chronic pain related to appendicitis
Constipation related to decreased bowel motility and decreased fluid intake
The Correct Answer is B
A. Imbalanced nutrition: Less than body requirements related to decreased oral intake: While this may be relevant, it is not the highest priority in acute appendicitis. Infection prevention is more critical.
B. Risk for infection related to possible rupture of appendix: The primary concern in appendicitis is the risk of rupture, leading to peritonitis and sepsis. This makes infection control the top priority.
C. Chronic pain related to appendicitis: Pain in appendicitis is acute, not chronic. Managing infection risk is more urgent.
D. Constipation related to decreased bowel motility and decreased fluid intake: Constipation is not a priority concern in the context of acute appendicitis. The risk of infection takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notify the health care provider: While it may eventually be necessary to notify the healthcare provider, the immediate action should involve confirming the balloon pressure, which is within the scope of respiratory therapy.
B. Call respiratory therapy to obtain the pressure within the balloon: This is the most appropriate action. Respiratory therapists are skilled in managing and measuring the cuff pressure to ensure it is within the correct range (typically 20-30 cm H2O).
C. Add air to the balloon port: Adding air without knowing the current pressure could lead to over inflation, which might cause tracheal injury.
D. Remove air from the balloon port: Similarly, removing air could lead to underinflation, increasing the risk of aspiration or inadequate ventilation.
Correct Answer is ["A","C","D"]
Explanation
A. Auscultate the chest for bilateral breath sounds: Auscultating the chest immediately after intubation ensures that the endotracheal tube is correctly placed in the trachea and not in the esophagus or a bronchus.
B. Assess the patient's blood glucose: Blood glucose monitoring is not immediately necessary following intubation.
C. Determine the CO2 level: Measuring end-tidal CO2 (ETCO2) is crucial to confirm that the tube is in the trachea and that ventilation is occurring effectively.
D. Obtain a stat PCXR (Portable Chest X-ray): A chest X-ray is obtained to confirm the correct placement of the endotracheal tube, ideally 2-3 cm above the carina.
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