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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 B

Explanation

Choice A rationale

While disposable gloves can reduce the transmission of pathogens, they should not replace proper hand hygiene. Gloves should be used when handling bodily fluids or when contact with infectious materials is likely, not necessarily for feeding an infant.

Choice B rationale

Keeping fingernails short and avoiding rings reduces the risk of harboring pathogens under nails and jewelry, which can be difficult to clean properly. This measure helps prevent the transmission of infections.

Choice C rationale

Washing hands up to the elbows is not necessary for routine home care and can cause skin irritation. Hand washing should focus on the hands and wrists, and the duration should be at least 20 seconds.

Choice D rationale

Home care still requires strict attention to medical asepsis, especially when caring for infants. Hand hygiene is necessary not only after toileting or handling soiled diapers but also before and after preparing food, feeding, and other activities.

A. Scabies. B. Tuberculosis. C. Scarlet fever. D. Mycoplasmal pneumonia.

Correct Answer is B

Explanation

Choice A rationale

Scabies is a parasitic skin infestation caused by mites. It spreads through direct skin-to-skin contact and does not require an N95 respirator. Standard precautions and contact isolation are usually sufficient.

Choice B rationale

Tuberculosis is an airborne infectious disease. An N95 respirator mask is necessary to protect against inhaling airborne droplets that may contain the bacteria, especially in healthcare settings.

Choice C rationale

Scarlet fever is a bacterial infection caused by group A Streptococcus. It spreads through respiratory droplets, but standard surgical masks are usually adequate. An N95 respirator is not required.

Choice D rationale

Mycoplasmal pneumonia is a type of bacterial pneumonia transmitted through respiratory droplets. While it can be contagious, an N95 respirator is generally not necessary unless in specific aerosol-generating procedures. Standard precautions are usually sufficient. .

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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)

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Naxlex Comprehensive Predictor Exams

A nurse teaching family members about hand hygiene in the home would emphasize:

Correct Answer is B

Explanation

A nurse is caring for a group of clients on an infectious disease unit. The nurse should wear an N95 respirator mask when caring for a client who has which of the following disorders?

Correct Answer is B

Explanation

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