The nurse is caring for a client who is diagnosed with appendicitis. Vital signs and lab values are as follows:
Heart Rate |
105 beats/minute. |
Blood Pressure |
130/85 mmHg |
Pain |
6 on a 0-10 scale |
Temperature |
101.3 F (38.5 C) |
White Blood Cell (WBC) |
12,000 mm3 (Ref: 4,000-10,000 mm3) |
Platelet Count |
150,000 mcl (Ret: 150,000-400,000 mcl) |
What actions should the nurse take pre and postoperatively? Drag all appropriate actions from the left side to the right side.
Administer an enema to prevent appendix from rupture.
Start IV fluids and administer antibiotics.
Ensure the surgical consent has been signed.
Keep the client NPO for surgery.
Monitor urine output to ensure adequate hydration status.
Administer pain medication via IV.
Correct Answer : B,C,D,E,F
A. Enemas and laxatives are contraindicated because they can increase intra-abdominal pressure and risk of appendix rupture.
B. IV fluids restore hydration, and antibiotics help prevent infection.
C. Consent must be signed before surgery.
D. Client should remain NPO to reduce aspiration risk during anesthesia.
E. Monitoring urine output is essential for assessing hydration and kidney perfusion.
F. IV pain medication is appropriate for pain control pre- and postoperatively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Bisphosphonates (e.g., alendronate, risedronate) must be taken on an empty stomach with a full glass of water in the morning to enhance absorption. No other food, drink, or medications should be taken for at least 30 minutes afterward.
B. Calcium supplements may still be prescribed in addition to bisphosphonates for osteoporosis management. They are not excluded.
C. Clients must remain upright (sitting or standing) for at least 30 minutes after ingestion to prevent esophageal irritation or reflux, not lie down.
D. Calcium supplements are often recommended, but they should be taken at a different time of day than bisphosphonates to avoid interference with absorption.
Correct Answer is ["A","C","F","G","H","L"]
Explanation
A. Warm blankets provide external rewarming.
B. The room should be kept warm, not decreased.
C. Warm IV fluids prevent further heat loss and aid internal rewarming.
D. Acetaminophen is for fever reduction, not for hypothermia management.
E. A fan would worsen heat loss.
F. Warmed, humidified oxygen prevents further cooling and helps raise core body temperature.
G. Cardiac monitoring is essential since hypothermia increases the risk for arrhythmias.
H. A radiant warmer provides effective external rewarming.
I. Monitoring core temperature ensures safe and effective rewarming.
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