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 D
Explanation
This aligns with the professional code of ethics for nurses, which states that nurses should respect the dignity, worth and rights of all human beings, regardless of the nature of their health problems or their social or legal status. The nurse should not let personal feelings or biases interfere with the quality of care or the ethical obligations of the profession.
Choice A is wrong because the nurse refuses to care of the client. This violates the principle of beneficence, which means doing good and preventing harm to others.
The nurse has a duty to provide care to all patients who need it, regardless of their personal opinions or feelings.
Choice B is wrong because the nurse delegates all care of the client to an assistant. This violates the principle of accountability, which means being answerable for one’s actions and decisions. The nurse cannot delegate tasks that require nursing judgment or assessment to an unlicensed person.
The nurse is responsible for ensuring that the patient receives safe and competent care.
Choice C is wrong because the nurse provides minimal care to keep the client alive. This violates the principle of non-maleficence, which means avoiding harm or injury to others.
The nurse should not provide substandard care or neglect the patient’s needs or preferences.
The nurse should strive to promote the health and well-being of the patient.
Correct Answer is D
Explanation
Localized warmth at the site of injury is a sign of localized inflammation of the tissues, which is a response to tissue damage caused by an ankle injury. Localized inflammation involves changes in blood flow, vessel permeability, and leukocyte migration to the site of injury. Heat is one of the five classic signs of acute local inflammation, along with redness, swelling, pain, and loss of function.
Choice A is wrong because 3+ palpable pedal pulses below the affected injury site indicate normal blood flow to the foot and do not reflect inflammation.
Choice B is wrong because full range of motion at the site of injury is unlikely in the presence of inflammation, which usually causes pain and loss of function.
Choice C is wrong because sanguineous drainage at the site of injury is a sign of bleeding, not inflammation.
Inflammation may cause fluid leakage from blood vessels, but this fluid is usually clear or yellowish, not bloody.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.