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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 C

Explanation

Choice A rationale

Requesting a Foley catheter for an older adult patient increases the risk of catheter-associated urinary tract infections (CAUTIs). Avoiding unnecessary catheterization is a better approach to prevent infections.

Choice B rationale

Offering a urinal every 2 hours may not significantly reduce the risk of urinary infections. While it encourages regular voiding, it does not address the need to keep urine dilute to prevent infections.

Choice C rationale

Encouraging fluid intake helps keep urine dilute, which reduces the risk of urinary tract infections. Adequate hydration flushes out bacteria and helps maintain a healthy urinary system.

Choice D rationale

While apple juice can help acidify urine, it is not the primary strategy for preventing urinary infections. Maintaining overall hydration with water is more effective in keeping the urine dilute and reducing infection risk.

A. I will wear gloves and a gown when bathing a client who has open skin lesions. B. I will wear gloves when measuring a client's BP. C. I will wear gloves to reduce the number of times I have to wash my hands. D. I will wear gloves whenever I am in contact with clients.

Correct Answer is A

Explanation

Choice A rationale

Wearing gloves and a gown when bathing a client who has open skin lesions is important to prevent the transmission of infectious agents and protect both the client and the caregiver. Open lesions are potential entry points for pathogens.

Choice B rationale

While wearing gloves when measuring blood pressure might seem like a precaution, it is unnecessary unless there is an anticipated exposure to blood or bodily fluids. Gloves are not routinely needed for measuring BP in non-infectious cases.

Choice C rationale

Using gloves to reduce the number of hand washes is not appropriate. Gloves should be worn to prevent contamination and infection, not to replace hand hygiene practices. Hand hygiene should still be performed before and after glove use.

Choice D rationale

Wearing gloves whenever in contact with clients may not be necessary for all interactions. Gloves should be worn based on the anticipated exposure to infectious materials, not indiscriminately, to avoid waste and maintain proper infection control.

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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

To prevent a urinary infection in an older adult patient who is in traction for a broken femur, the nurse would:

Correct Answer is C

Explanation

A nurse is reinforcing teaching with an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?

Correct Answer is A

Explanation

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