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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Before taking further action, the nurse should investigate whether there have been any changes in the client's diet, exercise routine, or lifestyle that may have contributed to the plateau in weight loss. Understanding any modifications made by the client can provide valuable insights into potential factors affecting their weight loss progress.
B. Bariatric surgery is a significant decision that requires careful consideration and evaluation of various factors. It is not appropriate to jump to this option without first exploring other potential reasons for the lack of weight loss.
C. While it's essential to review diet and exercise guidelines periodically to ensure the client is following appropriate recommendations, this option may not address the underlying cause of the recent lack of weight loss.
D. Regular weight monitoring is an important component of weight management and can provide valuable information about the client's progress. However, instructing the client to record weight weekly alone may not address the underlying reason for the lack of weight loss.
Correct Answer is D
Explanation
D. This candidate has obesity-related comorbidities such as hypertension and gallstones, which may indicate a higher risk of complications from obesity. With a BMI of 42, this individual meets the criteria for bariatric surgery. Additionally, being older than 18 years old and having obesity-related comorbidities make this candidate a potentially suitable candidate for bariatric surgery.
A. Bariatric surgery may not be appropriate for individuals with severe alcohol addiction or unstable cardiovascular conditions like congestive heart failure. Additionally, with a BMI of 30, this candidate is considered overweight but may not meet the criteria for bariatric surgery.
B. Bariatric surgery is not typically recommended for adolescents with a BMI in the normal weight range (18.5 to 24.9), such as this candidate. Furthermore, severe acne alone would not be a sufficient indication for bariatric surgery.
C. Bariatric surgery candidates should be mentally stable and capable of understanding and adhering to the necessary pre- and postoperative guidelines.
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