A nurse collecting data from a client who has manifestations of appendicitis. Where should the nurse palpate to monitor for pain at McBurney's point? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Answer and Explanation

The Correct Answer is "{\"xRanges\":[83.109375,104.109375],\"yRanges\":[119.5,140.5]}"

Draw an imaginary line connecting the ASIS to the umbilicus.

McBurney's point is located one-third of the distance along this line, starting from the ASIS and moving towards the umbilicus.

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Correct Answer is C

Explanation

A. Remove clothing. Removing clothing is important to prevent further injury from retained heat or chemicals, but it is not the first priority compared to ensuring a patent airway and adequate breathing.
B. Administer pain medication. Pain management is important but comes after ensuring the child's airway and respiratory status are stable.
C. Assess respiratory status. Burns on the face and chest can compromise the airway and breathing. Assessing respiratory status is the first priority to ensure the child’s airway is not obstructed and that they are receiving adequate oxygen.
D. Insert a Foley catheter. Inserting a Foley catheter may be necessary to monitor urine output and assess kidney function in severe burns, but it is not the first priority compared to assessing respiratory status.

A. Sun exposure B. Allergic reaction C. Infection D. Heat and moisture

Correct Answer is D

Explanation

A. Sun exposure: Sun exposure typically causes sunburn rather than tiny pinhead-sized papules.
B. Allergic reaction: Allergic reactions often present with different types of lesions or hives, not typically tiny papules.
C. Infection: Infections might cause different types of lesions or pustules rather than the described tiny papules.
D. Heat and moisture: Heat rash (miliaria) results from blocked sweat ducts, leading to tiny red papules due to overheating and trapped sweat, commonly occurring in areas like the neck and axilla.

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A nurse collecting data from a client who has manifestations of appendicitis. Where should the nurse palpate to monitor for pain at McBurney's point? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child is brought to the emergency department with burns on the face and chest. What is the nurse's first priority?

Correct Answer is C

Explanation

A mother is concerned about what might have caused a heat rash on her infant. The nurse observes tiny pinhead-sized reddened papules on the infant's neck and axilla. What does the nurse explain as the most likely cause of this rash?

Correct Answer is D

Explanation

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