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 C
Explanation
Choice A rationale:
Notifying the surgeon of the temperature elevation is important, but it is not the nurse's priority. A temperature elevation after abdominal surgery could be a sign of infection, but the immediate action should be to assess the surgical incision for any signs of infection.
Choice B rationale:
Encouraging the client to drink more fluids is a good practice to maintain hydration and promote recovery after surgery. However, it is not the nurse's priority in this situation. The elevated temperature and potential infection take precedence over increasing fluid intake.
Choice C rationale:
This is the correct answer because the nurse's priority is to assess the surgical incision for signs of infection. An elevated temperature is a significant finding after surgery, and it may indicate a surgical site infection, which requires prompt assessment and intervention.
Choice D rationale:
Monitoring vital signs every 4 hours is an essential nursing intervention after surgery, but it is not the priority when the client has an elevated temperature and a recent surgical incision.
The nurse must first assess for signs of infection before proceeding with routine vital sign monitoring.
Correct Answer is A
Explanation
The client's daily peak expiratory flow (PEF) measures 85% above personal best.
Choice A rationale:
Salmeterol is a long-acting beta-agonist used to treat asthma. Improvement in the client's daily peak expiratory flow (PEF) of 85% above their personal best indicates effective bronchodilation and better asthma control.
Choice B rationale:
ABGs showing a pH level of 7.32 are not indicative of the effectiveness of salmeterol. ABG values assess the client's acid-base balance and gas exchange, but they do not directly reflect the action of the medication.
Choice C rationale:
A decrease in forced expiratory volume after treatment with medication indicates a lack of response to the therapy, not an effective outcome. It suggests the medication is not adequately controlling the client's asthma symptoms.
Choice D rationale:
Wheezing limited to expiration is not a clear indicator of medication effectiveness. Wheezing can be present in various respiratory conditions and is not solely associated with asthma control. Exhibit. The correct answer is choice B: Increase the rate of the infusion by 160 units/hr.
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