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.

Answer and Explanation

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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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.

Correct Answer is ["1.5"]

Explanation

• Desired dose: 15,000 units
• Available concentration: 10,000 units/mL
• To find the volume to administer, we can use the formula:
• Volume to administer (mL) = Desired dose (units) / Concentration (units/mL)
• Volume to administer = 15,000 units / 10,000 units/mL = 1.5 mL

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A nurse is preparing a client who has acute appendicitis for surgery. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is ["1.5"]

Explanation

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