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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "You should not have sexual intercourse while the monitor is in place.": This is incorrect because sexual activity is generally not restricted while wearing a Holter monitor. The main focus is on ensuring the monitor remains attached.
B. "You can bathe while wearing the electrodes.": This is incorrect because bathing or getting the electrodes wet can interfere with the monitor's functionality and potentially lead to inaccurate readings.
C. "You should remove the electrodes when you go to bed.": This is incorrect because the electrodes should remain in place for the full 24-hour period to ensure continuous monitoring.
D. "You will need to record daily activities in a diary.": This is correct as recording activities in a diary is crucial for correlating symptoms with the Holter monitor data.
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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