A client continues to report nausea following surgery from the anesthesia. She has received an antiemetic, and the next dose is not due for another hour. What should the nurse do first?

Explore non-pharmacological options for nausea

Offer to notify the healthcare provider after morning rounds are completed

Discuss how anesthesia can cause nausea after surgery

Explain to the patient that nothing else has been ordered

Answer and Explanation

The Correct Answer is A

Choice A reason: Non-pharmacological options, like acupressure or aromatherapy, address nausea without medication risks. These interventions stimulate the parasympathetic nervous system or reduce gastric irritation, providing relief. Acting first with these methods is safe, effective, and aligns with holistic care, especially when the next antiemetic dose is not yet due.

Choice B reason: Notifying the provider after rounds delays intervention, as nausea requires prompt relief to prevent distress or vomiting. This approach does not address the client’s immediate need and may prolong discomfort. Non-pharmacological methods should be tried first, as they are within the nurse’s scope and can provide quicker relief.

Choice C reason: Discussing anesthesia’s role in nausea provides education but does not alleviate the client’s current symptoms. This cognitive approach addresses understanding, not immediate comfort. While education is valuable, the priority is relieving nausea, making non-pharmacological interventions a more appropriate first step in this scenario.

Choice D reason: Explaining that no other medications are ordered dismisses the client’s discomfort and does not provide relief. This approach fails to utilize the nurse’s scope to implement non-pharmacological interventions, which can effectively manage nausea. It may also reduce trust, as it does not address the client’s immediate needs.

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Correct Answer is A

Explanation

Choice A reason: Rebound tenderness at McBurney’s point (right lower quadrant) indicates peritoneal irritation, a hallmark of appendicitis. The inflamed appendix causes localized pain, exacerbated by pressure release due to peritoneal inflammation. This specific finding is highly suggestive of appendicitis, distinguishing it from other abdominal conditions.

Choice B reason: Left lower quadrant pain is not typical for appendicitis, which usually presents in the right lower quadrant due to the appendix’s anatomical location. Left-sided pain may suggest conditions like diverticulitis or colitis, but it does not align with the localized inflammation characteristic of appendicitis.

Choice C reason: High-pitched bowel sounds suggest increased peristalsis, as in early obstruction, but are not specific to appendicitis. Appendicitis may reduce bowel sounds due to peritoneal irritation. Rebound tenderness is a more direct indicator, as it reflects the localized inflammation and irritation of appendicitis.

Choice D reason: A soft, non-tender abdomen is inconsistent with appendicitis, which causes localized pain and tenderness due to inflammation. A non-tender abdomen suggests a normal or alternative condition, not appendicitis, where peritoneal irritation typically produces tenderness, especially at McBurney’s point, upon palpation or rebound.

A. Hyperchloremia B. Hypercalcemia C. Hypocalcemia D. Hypomagnesemia

Correct Answer is C

Explanation

Choice A reason: Hyperchloremia, elevated chloride levels, is associated with metabolic acidosis or dehydration, not neuromuscular symptoms like wrist flexion. Chloride imbalances affect acid-base balance, not calcium-dependent muscle contractions. The inward wrist flexion suggests a neuromuscular excitability issue, which is more characteristic of low calcium levels than chloride abnormalities.

Choice B reason: Hypercalcemia, high calcium levels, causes muscle weakness, lethargy, and reduced reflexes, not increased neuromuscular excitability like wrist flexion. Calcium excess stabilizes nerve membranes, reducing spasms. The symptom described aligns with hypocalcemia, where low calcium increases nerve excitability, leading to tetany or abnormal muscle contractions.

Choice C reason: Hypocalcemia, low calcium levels, increases neuromuscular excitability due to decreased stabilization of nerve membranes. This can cause tetany, characterized by involuntary muscle contractions, such as wrist flexion (carpopedal spasm). The symptom is a classic sign of hypocalcemia, often seen in conditions like hypoparathyroidism or vitamin D deficiency.

Choice D reason: Hypomagnesemia, low magnesium, can cause neuromuscular symptoms like tremors or seizures but is less commonly associated with specific signs like wrist flexion. Magnesium affects muscle relaxation, and its deficiency typically causes generalized excitability. Hypocalcemia is more directly linked to tetany and carpopedal spasms, as seen in the client.

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A client continues to report nausea following surgery from the anesthesia. She has received an antiemetic, and the next dose is not due for another hour. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a client with suspected appendicitis. Which physical assessment finding is most indicative of this condition?

Correct Answer is A

Explanation

As the nurse assesses a client’s blood pressure, the patient’s wrist severely flexes inward. The nurse questions the client’s response because this finding may indicate what condition?

Correct Answer is C

Explanation

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