A nurse is planning care for a client who has acute appendicitis.
Which of the following actions should the nurse plan to take?
Administer a laxative to the client.
Keep the client on NPO status.
Place the client's head of bed flat.
Apply heat to the client's abdomen.
The Correct Answer is B
Choice A rationale:
Administering a laxative to a client with acute appendicitis is contraindicated. Laxatives can increase bowel motility, which may aggravate the inflamed appendix and lead to rupture. Rupture of the appendix can result in a life-threatening condition known as peritonitis.
Choice B rationale:
Keeping the client on NPO (nothing by mouth) status is the correct choice. NPO status is essential in the management of acute appendicitis. It helps to rest the bowel, prevents stimulation of the appendix, and decreases the risk of rupture. Oral intake, including food and fluids, is usually restricted until the client undergoes surgery to remove the inflamed appendix (appendectomy).
Choice C rationale:
Placing the client's head of bed flat is not the optimal position for a client with acute appendicitis. Elevating the head of the bed slightly (semi-Fowler's position) can help reduce discomfort and minimize pressure on the abdomen. This position is more comfortable for the client and can aid in pain management.
Choice D rationale:
Applying heat to the client's abdomen is not recommended in acute appendicitis. Heat application can increase blood flow to the area, potentially worsening inflammation and exacerbating pain. Cold packs or ice packs are sometimes used to provide comfort, but their application should be done cautiously to avoid skin damage. However, in many cases, healthcare providers prefer to avoid temperature applications to prevent masking symptoms and signs of worsening appendicitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
No explanation
Correct Answer is A
Explanation
A) "My child has some swelling around her eyelids and mouth."
In this scenario, the parent reporting swelling around the toddler's eyelids and mouth after receiving immunizations is the nurse's priority concern. Swelling around the eyes and mouth can be indicative of a possible allergic reaction, such as angioedema or anaphylaxis, which can be a serious and life-threatening condition. Immediate assessment and intervention are needed to address this potential allergic reaction.
The other findings, while important, are not as immediately concerning:
B) A temperature of 100.7 degrees Fahrenheit is a mild fever, which can be expected as a side effect of some vaccines. It may not be the nurse's immediate priority, but it should still be monitored.
C) A toddler's decreased feeding of 2 ounces during her last feeding may be related to her discomfort or fever after immunizations. It's essential to monitor this but not an immediate priority.
D) Crying when touched at the injection site is a common response to immunizations and, while uncomfortable for the child, is not typically a cause for immediate concern. However, it should still be addressed with comfort measures.
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