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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Increasing regular weight-bearing activities can help prevent osteoporosis by stimulating bone formation and improving muscle strength. Weight-bearing activities are those that make your bones and muscles work against gravity, such as walking, jogging, dancing, or lifting weights.

Choice A is wrong because protecting the client’s bones with strict bedrest can actually increase the risk of osteoporosis by reducing bone density and muscle mass. Bedrest should be avoided unless medically necessary.

Choice B is wrong because providing the client with assisted range of motion exercises twice daily is not enough to prevent osteoporosis. While these exercises can help maintain joint mobility and flexibility, they are not weight bearing and do not stimulate bone formation.

Choice C is wrong because decreasing the amount of calcium in the client’s diet can also increase the risk of osteoporosis. Calcium is an essential mineral for bone health and adults need 700mg a day, which can be obtained from foods such as dairy products, leafy green vegetables, tofu, and dried fruit. Vitamin D is also important for bone health as it helps the body absorb calcium.

A. Administer the prescribed medication. B. Reposition the client and apply a heating pad on the warm setting to the client’s abdomen. C. Call the healthcare provider. D. Call and ask the operating room team to perform surgery as soon as possible.

Correct Answer is C

Explanation

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.

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Naxlex Comprehensive Predictor Exams

A client who is at risk for developing osteoporosis asks what can be done to decrease the risk of actually developing the disorder. Which intervention would be the most beneficial for this client?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

A nurse is teaching a newly licensed nurse about informed consent. Which of the following should be included as a responsibility of the nurse in this process?

The nurse knows that infants have a high risk of hypothermia due to decreased brown fat, immature skin, and poorly developed thermoregulatory mechanism. Which nursing intervention is done to prevent heat loss by conduction?

An elderly client is admitted to the hospital looking unkempt, with dirty clothing, and she smells of urine. The nurse is aware this may be:

In individuals who have appendicitis, the pain will typically localize to McBurney’s point. Which quadrant of the abdomen is McBurney’s point found?