A nurse in an emergency department is caring for a client who has appendicitis. Which of the following actions should the nurse take?
Maintain the client in a semi-Fowler's position.
Administer an enema 1 hr prior to surgery.
Apply a warm pack to the client's lower abdomen.
Place the client on a clear liquid diet.
The Correct Answer is A
Choice A rationale:
The nurse should maintain the client in a semi-Fowler's position to promote comfort and reduce the risk of complications related to appendicitis. This position helps to decrease pressure on the abdomen and may alleviate pain by reducing tension on the abdominal muscles.
Choice B rationale:
Administering an enema 1 hour prior to surgery is not indicated for a client with appendicitis. Enemas are generally not recommended for clients with suspected or confirmed appendicitis as they can potentially worsen inflammation and cause perforation of the inflamed appendix.
Choice C rationale:
Applying a warm pack to the client's lower abdomen is contraindicated in appendicitis. Heat can exacerbate inflammation and should be avoided in such cases.
Choice D rationale:
Placing the client on a clear liquid diet is not appropriate for appendicitis. Clients with appendicitis are typically NPO (nothing by mouth) to avoid stimulating the gastrointestinal tract and reduce the risk of rupture if surgery is needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Covering bedside water pitchers after being filled helps reduce the risk of contamination and infection by preventing the entry of airborne pathogens or debris.
Choice B rationale:
Allowing dressings that get wet in the shower to dry out is not an effective infection control strategy. Wet dressings can become a breeding ground for bacteria, and it is important to change wet dressings promptly to minimize the risk of infection.
Choice C rationale:
Used needles should be immediately disposed of in sharps containers, not placed at the nurses' station. Placing used needles in the sharps container promptly helps prevent accidental needlestick injuries and potential transmission of infections.
Choice D rationale:
Drainage bottles should be emptied regularly to prevent overfilling, but they should not be allowed to become full. Regular emptying ensures proper functioning and reduces the risk of spillage or contamination in the client care area.
Correct Answer is D
Explanation
Choice A rationale:
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
Choice B rationale:
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
Choice C rationale:
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
Choice D rationale:
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today