The nurse is caring for a client who has suspected appendicitis. While waiting for surgery, nursing interventions for this client would include: (NOTE: Assume that there are physician's orders for all interventions which would require them.) (SELECT ALL THAT APPLY)

giving the client a heating pad to place on the abdomen for comfort.

getting the client up to walk at least once every hour.

administering a cleansing enema in preparation for surgery.

administering prophylactic IV antibiotics.

keeping the client NPO.

Answer and Explanation

Correct Answer : D,E

D. Prophylactic antibiotics are often administered before surgery for appendicitis to reduce the risk of postoperative infection, particularly in cases of suspected or confirmed appendiceal perforation.
E. Keeping the client NPO (nothing by mouth) is a standard precaution before surgery to prevent aspiration of gastric contents during anesthesia induction and to reduce the risk of surgical complications.
A. Applying heat to the abdomen can potentially worsen inflammation and increase the risk of appendiceal rupture.
B. Ambulation may exacerbate the pain and increase the risk of complications, such as appendiceal rupture.
C. Administering a cleansing enema in preparation for surgery may be appropriate in some cases to help prepare the bowel for surgery, particularly if there is concern about bowel obstruction or to reduce the risk of contamination during surgery.

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Correct Answer is B

Explanation

B. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can irritate the gastric mucosa and exacerbate gastritis symptoms, including nausea and vomiting. Therefore, aspirin would be contraindicated in a client with acute gastritis, especially if they are experiencing nausea and vomiting.
A. Amoxicillin is an antibiotic commonly used to treat bacterial infections associated with gastritis or peptic ulcers. Therefore, amoxicillin would generally be an appropriate medication for treating gastritis if the underlying cause is bacterial infection.
C. Ranitidine helps alleviate symptoms such as heartburn and indigestion by reducing stomach acid production.
D. Pantoprazole is a proton pump inhibitor (PPI) that is commonly used to treat gastric acid-related disorders, including gastritis and gastroesophageal reflux disease (GERD).

A. Sit the client up and provide supplemental oxygen B. Contact the physician and obtain an arterial blood gas C. Explain that this is an expected finding after surgery D. Encourage the use of the incentive spirometer

Correct Answer is A

Explanation

A. Sit the client up and provide supplemental oxygen is the correct priority intervention. Chest pain and shortness of breath can be indicative of pulmonary embolism or other respiratory complications, which require immediate attention. Sitting the client up helps improve respiratory mechanics, and providing supplemental oxygen can support oxygenation while further assessments are conducted.
B. While contacting the physician and obtaining an arterial blood gas may be necessary to assess respiratory status and oxygenation, it is not the immediate priority. The client's symptoms require immediate intervention to ensure adequate oxygenation and prevent further deterioration.
C. Chest pain and shortness of breath are not typically expected findings after bariatric surgery and could indicate serious complications. It is essential not to dismiss the client's symptoms but to take them seriously and initiate appropriate interventions.
D. While the use of an incentive spirometer is important for preventing respiratory complications after surgery, it is not the priority intervention in this situation. The client's current symptoms require immediate attention to address potential respiratory distress or other serious complications.

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The nurse is caring for a client who has suspected appendicitis. While waiting for surgery, nursing interventions for this client would include: (NOTE: Assume that there are physician's orders for all interventions which would require them.) (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has acute gastritis due to food poisoning. The client is experiencing nausea and vomiting. The nurse would question which of the following medications, if ordered?

Correct Answer is B

Explanation

The nurse is assessing a client after bariatric surgery. The client complains of chest pain and shortness of breath. What is the priority nursing Intervention at this time?

Correct Answer is A

Explanation

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