A client admitted with a diagnosis of appendicitis calls the nurse and states, "Do you think I'll still need surgery? My pain suddenly stopped, and I feel much more comfortable now when I bend my knees." Which action should the nurse take?

Administer intravenous antibiotic.

Place in high Fowler's position.

Determine last dose of analgesic.

Prepare for emergency surgery.

Answer and Explanation

The Correct Answer is D

A. Administer intravenous antibiotic: Antibiotics are often given as part of appendicitis management, but sudden pain relief may indicate appendix rupture. At this point, the priority is rapid surgical intervention, not antibiotics alone.

B. Place in high Fowler's position: Positioning may help with comfort but does not address the urgent complication of a possible perforated appendix. It is a supportive measure, not a definitive response to the change in symptoms.

C. Determine last dose of analgesic: While it is important to know when pain medication was last administered, relying on this alone could delay recognition of a surgical emergency. Sudden absence of pain in appendicitis is rarely due to analgesia but often due to perforation.

D. Prepare for emergency surgery: A sudden decrease in pain in appendicitis is concerning for rupture, as pressure is relieved when the appendix bursts. This is a life-threatening complication requiring immediate surgical evaluation and intervention.

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Correct Answer is C

Explanation

A. Monitor for desquamation and normal flora overgrowth: While monitoring skin integrity is important, this does not directly prevent the primary complication of scabies, which is secondary bacterial infection from scratching.

B. Wash skin between application of topical antiparasitic doses: Washing between doses can remove the medication prematurely, reducing its effectiveness. The lotion should remain on for the prescribed time before being washed off.

C. Keep the child's nails short and encourage use of hand mittens: Trimming nails and using mittens reduce scratching and skin breakdown, which lowers the risk of bacterial superinfection, the main complication of scabies in children.

D. Shave the body hair before applying the scabicide lotion: Shaving is not recommended, as scabicide is effective when applied to the skin surface. Shaving may cause irritation and increase discomfort without improving treatment outcomes.

A. Maintain strict intake and output. B. Monitor blood glucose level. C. Assess warmth of extremities. D. Keep head of bed raised 45 degrees.

Correct Answer is A

Explanation

A. Maintain strict intake and output: In septic shock, monitoring fluid balance is critical because clients are at high risk for hypovolemia, organ dysfunction, and multi-organ failure. Accurate intake and output measurements guide fluid resuscitation and help evaluate response to therapy.

B. Monitor blood glucose level: Hyperglycemia can occur in sepsis and should be monitored, but it is secondary to maintaining adequate perfusion and fluid balance. Glucose monitoring supports overall care but is not the immediate priority in shock management.

C. Assess warmth of extremities: Extremity warmth or coolness provides information about perfusion and circulatory status but is observational. It does not actively intervene to reverse the pathophysiologic processes of septic shock.

D. Keep head of bed raised 45 degrees: Elevating the head of the bed may reduce aspiration risk, but it does not address the urgent need to manage hypoperfusion, organ perfusion, and fluid status in septic shock.

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A client admitted with a diagnosis of appendicitis calls the nurse and states, "Do you think I'll still need surgery? My pain suddenly stopped, and I feel much more comfortable now when I bend my knees." Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a child who is suffering from persistent itching due to scabies. Which measure should the nurse implement to minimize this child's risk for complications?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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