The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes the abdomen is distended and bowel sounds are diminished.
Which is the most appropriate nursing intervention?
Administer the prescribed medication.
Reposition the client and apply a heating pad on the warm setting to the client’s abdomen.
Call the healthcare provider.
Call and ask the operating room team to perform surgery as soon as possible.
The Correct Answer is C
The client may have a ruptured appendix, which is a life-threatening complication of appendicitis. A ruptured appendix can cause peritonitis, which is an infection of the lining of the abdomen, or an abscess, which is a collection of pus around the appendix. These conditions require immediate medical attention and surgery to remove the appendix and clean the abdominal cavity.
Choice A is wrong because administering the prescribed medication may mask the symptoms of a ruptured appendix and delay diagnosis and treatment.
Choice B is wrong because repositioning the client and applying a heating pad may increase the risk of rupture or spread of infection.
Choice D is wrong because calling the operating room team is not the nurse’s responsibility and may not be feasible depending on the availability of the surgical team and the operating room.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Fluid volume excess is wrong because appendicitis does not cause fluid retention or overload. It may cause fluid loss due to vomiting, fever, or rupture of the appendix. Therefore, a more appropriate nursing diagnosis would be the risk for deficient fluid volume.
Choice B. Risk for infection is correct because appendicitis is an inflammatory condition that can lead to bacterial infection, especially if the appendix ruptures and causes peritonitis or abscess formation.
Choice C. Ineffective thermoregulation is correct because appendicitis can cause fever due to inflammation and infection.
Choice D. Pain is correct because appendicitis causes acute abdominal pain that usually starts in the periumbilical area and then localizes to the right lower quadrant. The pain may be accompanied by nausea, vomiting, and rebound tenderness.
Correct Answer is D
Explanation
This is because the fight-or-flight response activates the sympathetic nervous system, which causes the pupils to dilate to allow more light and improve vision.
Choice A is wrong because the fight-or-flight response increases blood pressure by constricting blood vessels and increasing heart rate.
Choice B is wrong because the fight-or-flight response causes bronchial airway dilation to allow more oxygen intake and facilitate breathing.
Choice C is wrong because the fight-or-flight response causes hyperglycemia by stimulating the release of glucose from the liver and muscles to provide energy.
Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg, for blood glucose are 70 mg/dL to 100 mg/dL, and for pupil size are 2 mm to 6 mm.
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