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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Hypovolemic shock causes decreased renal perfusion and is associated with prerenal acute kidney injury, not post renal.

B. Long-term NSAID use can cause intrarenal acute kidney injury by damaging renal tissue through inhibition of prostaglandin synthesis and decreased renal blood flow.

C. Acute glomerulonephritis results in intrarenal acute kidney injury due to inflammation and damage to the glomeruli.

D. Benign prostatic hyperplasia (BPH) can cause urinary tract obstruction by compressing the urethra, leading to urinary retention and backflow of urine into the kidneys. This obstruction results in post renal acute kidney injury.

A. "Have you been under any emotional and physical stress lately?" B. "Have you recently received the influenza vaccine?" C. "Have you added any grapefruit juice to your diet lately?" D. "Have you been out of the country in the past couple of months?"

Correct Answer is A

Explanation

A. Exacerbations of multiple sclerosis (MS) are often triggered by stress, infection, fatigue, or extreme temperatures. Asking about emotional and physical stress is the most appropriate way to explore a likely cause for the relapse.
B. The influenza vaccine does not cause MS exacerbations and is generally recommended to help prevent infections, which can actually trigger relapses.
C. Grapefruit juice can interact with some medications, but it is not associated with MS exacerbations.
D. Travel history may be important for infectious disease screening but is not directly related to MS relapse triggers.

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Heart Rate	115 beats per minute
Blood pressure	100/70 mmHg
Temperature	98.7 F (37.0 C)
Oxygen saturation	90% on room air

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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for several clients with acute kidney injury. Which client is most at risk for developing post renal acute kidney injury?

Correct Answer is D

Explanation

The nurse is admitting a client with an exacerbation of multiple sclerosis. The client states, "I have been in remission for years and cannot imagine what might have caused this." Which question would be the best one to ask in trying to determine the cause of the relapse?

Correct Answer is A

Explanation

The nurse is planning care for a child who has tinea pedis. Which action should the nurse include in the plan of care?

The home health nurse is caring for a client who was recently diagnosed with advanced pancreatic cancer. Which statement best indicates that the client is experiencing the anger phase of grief?

The nurse is receiving morning report on several clients with diseases causing inflammation. What client is the priority for the nurse to assess first?

The nurse is caring for a client with cellulitis on the leg. Which statement by the client indicates a need for additional education regarding cellulitis?

The nurse is caring for a client who is ready to be discharged home after a cataract extraction with intraocular lens implant. The nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which symptom is the priority for the nurse to teach the client?

The nurse is caring for a client with diverticulitis. Vitals are as follows. What laboratory value is the priority to report to the healthcare provider? Heart Rate 115 beats per minute Blood pressure 100/70 mmHg Temperature 98.7 F (37.0 C) Oxygen saturation 90% on room air

The nurse is assessing a client in the clinic. Which assessment findings indicate that the client may have benign prostatic hyperplasia (BPH)? (Select all that apply)