A nurse is preparing a client who has acute appendicitis for surgery. Which of the following actions should the nurse take?
Apply a heat pack to the client's lower abdomen.
Place the client in semi-Fowler's position.
Give the client a clear liquid diet.
Administer an enema to the client.
The Correct Answer is B
A. Apply a heat pack to the client's lower abdomen: This is incorrect as applying heat can worsen inflammation and increase the risk of rupture; ice packs are generally used instead.
B. Place the client in semi-Fowler's position: This is correct as the semi-Fowler's position helps reduce pain and pressure on the abdomen and can improve comfort before surgery.
C. Give the client a clear liquid diet: This is incorrect as a clear liquid diet is not appropriate for a client with acute appendicitis who may require NPO (nothing by mouth) status prior to surgery.
D. Administer an enema to the client: This is incorrect as enemas are contraindicated in acute appendicitis due to the risk of perforation and worsening of the condition.
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Related Questions
Correct Answer is D
Explanation
A. "My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke": This is incorrect as glucocorticoids are not typically used to reduce stroke risk; they are more commonly used to manage inflammation and other conditions.
B. "Having a total cholesterol level below 200 mg/dL increases my risk for a stroke": This is incorrect because having a total cholesterol level below 200 mg/dL is generally considered desirable and lowers the risk of stroke.
C. "My risk for a stroke increases if my HbA1c level is 6 percent or less": This is incorrect because an HbA1c level of 6 percent or less is generally considered well-managed for diabetes and does not increase stroke risk; higher levels are more concerning.
D. "I can decrease my risk for a stroke by losing excess weight": This is correct as losing excess weight can reduce the risk of stroke by improving overall cardiovascular health and managing diabetes.
Correct Answer is B
Explanation
A. The skin around the client's stoma is bulging: While bulging skin can be concerning, it is often a normal postoperative finding as the stoma settles into its new position. However, further evaluation may be needed if other symptoms are present.
B. The client has had no fecal output from the stoma: This is correct as the absence of fecal output 24 hours postoperatively could indicate a potential issue such as a blockage or anastomotic failure, which requires prompt evaluation by the provider.
C. The stoma protrudes 2 cm (0.8 in) above client's abdominal wall: This is generally considered normal. The stoma should protrude slightly to ensure it is not retracted and is functioning properly.
D. The client's stoma is moist and beefy red: This is a normal finding. A healthy stoma should be moist and beefy red, indicating good blood flow and viability.
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