A nurse in the emergency department (ED) is caring for a 13-year-old client who presented with right lower quadrant abdominal pain, nausea, and fever.
(Select all that apply.)
Administer laxative
Administer enemas until clear
Maintain NPO status
Administer acetaminophen 800 mg
Obtain abdominal ultrasound
Initiate IV antibiotics
Correct Answer : C,D,E,F
A. Administering a laxative would not be appropriate in this scenario because the client is presenting with symptoms suggestive of an acute abdomen, which could be indicative of a serious condition like appendicitis. Laxatives could potentially worsen the condition or mask important symptoms.
B. Administering enemas until clear is not indicated in this situation. It could potentially delay appropriate diagnosis and treatment of the underlying cause of the client's symptoms, such as appendicitis. Additionally, enemas may be contraindicated if there is suspicion of bowel obstruction or perforation.
C. Given the symptoms of right lower quadrant abdominal pain, nausea, and vomiting, along with the elevated WBC count and C-Reactive Protein level, maintaining NPO (nothing by mouth) status is appropriate to rest the bowel and prevent potential exacerbation of symptoms.
D. Acetaminophen will help alleviate the client’s pain, while preparing them for an appendectomy.
E. The client's presentation with right lower quadrant abdominal pain, along with the elevated WBC count, warrants further investigation to rule out appendicitis. An abdominal ultrasound can help confirm the diagnosis and guide further management.
F. With the clinical suspicion of appendicitis supported by the elevated WBC count, initiation of IV antibiotics is indicated to treat possible infection and prevent complications associated with appendicitis, such as perforation or abscess formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While burping the baby more frequently might help with gas, projectile vomiting after feeding could indicate a more serious issue that requires immediate attention.
B. Giving an oral rehydration solution is not appropriate for a 2-month-old infant experiencing projectile vomiting after feeding; medical evaluation is needed.
C. Projectile vomiting in a young infant could indicate a serious problem such as pyloric stenosis, which requires immediate medical evaluation.
D. Switching formula may not address the underlying cause of projectile vomiting and could delay appropriate treatment; medical evaluation is needed.
Correct Answer is C
Explanation
A. A slow, bounding pulse is not typically associated with dehydration; tachycardia is more common.
B. Tetany is not typically seen in dehydration but can occur in severe cases of electrolyte imbalance.
C. Irritability is a common behavioral sign of dehydration, especially in infants.
D. Decreased temperature is not a typical finding in dehydration; fever may be present due to underlying illness causing the dehydration.
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