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The nurse is caring for a client with suspected appendicitis. Nursing interventions for this client would include: (SELECT ALL THAT APPLY)

Withholding food and fluids until a diagnosis is established.

Administering prophylactic IV antibiotics.

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

Administering a cleansing enema in preparation for surgery.

Having the client ambulate at least once every hour.

Answer and Explanation

Correct Answer : A,B

Choice A rationale

Withholding food and fluids is essential to prevent complications should surgery be needed.

Choice B rationale

Administering prophylactic IV antibiotics helps prevent infection, which is critical in cases of appendicitis.

Choice C rationale

Applying heat to the abdomen can increase circulation and the risk of rupture in appendicitis.

Choice D rationale

Administering an enema can increase the risk of perforation in appendicitis.

Choice E rationale

Ambulation can exacerbate pain and the risk of rupture in a client with suspected appendicitis.

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Correct Answer is A

Explanation

Choice A rationale

Suctioning a tracheotomy involves contact with respiratory secretions which can be infectious. Protective eyewear is necessary to prevent exposure to potentially infectious fluids.

Choice B rationale

Changing a baby’s diaper involves exposure to feces and urine, but does not usually require protective eyewear as splashing is not common.

Choice C rationale

Applying a dressing on the leg generally does not involve significant risk of splashes or sprays to the eyes, making protective eyewear unnecessary.

Choice D rationale

Gathering linens off a contaminated bed poses some risk of contamination, but typically does not involve splashes or sprays that would necessitate protective eyewear.

A. 7 minutes. B. 6 minutes. C. 5 minutes. D. 3 minutes.

Correct Answer is C

Explanation

Choice A rationale

While a scrub time of 7 minutes can be effective, it exceeds the necessary average time and may cause skin irritation with prolonged scrubbing.

Choice B rationale

A 6-minute scrub is also effective but similarly exceeds the average time, which is typically shorter to balance effectiveness and skin health.

Choice C rationale

A 5-minute scrub is the standard average time, balancing thoroughness in removing transient microorganisms with skin integrity.

Choice D rationale

A 3-minute scrub is often considered too short to ensure adequate removal of microorganisms, potentially compromising aseptic technique.

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The nurse is caring for a client with suspected appendicitis. Nursing interventions for this client would include: (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The situation in which protective eyewear is required is:

Correct Answer is A

Explanation

The nurse performing a surgical scrub is aware that the average time for the scrub is:

Correct Answer is C

Explanation

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