A nurse is caring for a client who is scheduled for an appendectomy.

Exhibit 1 Exhibit 2 Exhibit 3

Nurses' Notes

1050:

Received handoff report from the ED nurse for a client who has acute appendicitis and is scheduled for an appendectomy. Client reports that pain began in the midabdominal region during the night. This morning the pain intensified and localized to the right lower quadrant region. Pain continues to intensify. rebound tenderness noted. Reports vomiting one time after eating a piece of toast at 0600 with continued feelings of nausea.

Peripheral IV to the left forearm with IV fluids infusing.

1200:

Informed consent obtained by the surgeon performing the procedure. Placed in the client's medical record. Client expressing concern about potential complications that could result from the surgery.

Medical History

1050:

Received influenza vaccine 1 month ago.

Thyroid disease, taking levothyroxine for 14 years. History of cholecystectomy 3 years ago.

Denies alcohol or illegal drug use. Reports smoking approximately 6 cigarettes per day for the past 10 years. Allergic to shellfish, latex, and penicillin.

Vital Signs

0945, Upon admission to emergency department (ED): Temperature 38.3°C(100.9° F)

Pulse rate 102/min Respiratory rate 22/min

Blood pressure 122/80 mm Hg Oxygen saturation 96% on room air Pain reported as 6 on a scale of 0 to 10.

1050, Upon admission to medical-surgical department Temperature 38,4° C (101.2° F)

Pulse rate 104/min Respiratory rate 22/min

Blood pressure 124/80 mm Hg Oxygen saturation 96% on room air Pain reported as 8 on a scale of 0 to 10

The nurse is preparing the client for surgery. Select the 4 findings that require follow-up prior to surgery.

Dietary intake

Oxygen saturation

Pain level

Blood pressure

Allergies

Informed consent

Answer and Explanation

Correct Answer : A,C,E,F

A.   The nurse asks the client when was the last time they ate or drank anything, and verifies that they are fasting according to the preoperative instructions. Dietary intake is important because the client should have an empty stomach to prevent aspiration during anesthesia.

B.   The oxygen saturation remains at 96% on room air, which is within the normal range. No immediate follow-up is needed based on this parameter.
C.   The client's pain level has increased from 6 to 8 on a scale of 0 to 10. This increase in pain intensity requires further assessment and intervention to ensure adequate pain management before surgery.
D.   The client's blood pressure remains relatively stable within normal limits.

However, the increase in pain intensity may impact blood pressure, and it's essential to monitor for any significant changes.
E. The allergies are important to identify because the client is allergic to shellfish, latex, and penicillin, which could cause anaphylaxis or other adverse reactions during surgery or anesthesia. The nurse should ensure that the client is wearing an allergy bracelet and that the surgical team is aware of the allergies.
F. The informed consent is essential to obtain before any invasive procedure. The nurse should verify that the client understands the risks, benefits, and alternatives of the surgery and that the consent form is signed and witnessed.

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Correct Answer is B

Explanation

A. While it may be necessary to notify risk management eventually, the immediate priority is to ensure the client's safety and well-being.
B. The nurse should promptly assess the client for signs and symptoms of an allergic reaction and initiate appropriate interventions as necessary.
C. Documentation of the medication error and allergic reaction should be completed after ensuring the client's immediate needs are addressed.
D. Administering an antidote may be appropriate in certain situations, but the nurse should first assess the client's condition and follow established protocols for managing allergic reactions.

A. Obtain the client's type and cross-match. B. Inform the provider of the delay in obtaining the type and cross-match. C. Document the incident in the client's medical record. D. Prepare an incident report for risk management.

Correct Answer is A

Explanation

A. Obtaining the client's type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery.
B. This is important but should only be done after obtaining the client’s type and cross-match.
C. This should be done after obtaining the client’s type and cross-match.

D. While an incident report may be necessary, the immediate priority is to address the oversight and ensure patient safety.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering a medication to a client. The nurse identifies the client has an allergy to the medication after it has been administered. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

During change-of-shift report, a nurse discovers they overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?

A nurse is teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?

A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is assessing an older adult client's perception of sexuality. Which of the following statements made by the client indicates a need for intervention?

A nurse is observing a newly licensed nurse care for a client who is at increased risk for infection. Which of the following actions indicate the newly licensed nurse is following recommended medical asepsis practices?