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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Glucose and calcium levels: While hyperglycemia can occur secondary to stress, glucose and calcium are not the primary indicators of severity in a thyrotoxic crisis.
B. Blood and urine cultures: Cultures are important if infection is suspected as a trigger, but they do not reflect the systemic impact of a thyrotoxic crisis itself.
C. Renal and liver function tests: Thyrotoxic crisis can lead to multi-organ stress, including hepatic dysfunction and impaired renal perfusion. Monitoring liver enzymes and renal function helps detect complications early and guide interventions.
D. Electrolytes and hemoglobin: Electrolytes may fluctuate and anemia may exist, but they are not the most critical values to monitor during the acute phase of a thyrotoxic crisis compared with organ function indicators.
Correct Answer is C
Explanation
A. Temperature: While monitoring temperature is part of routine assessment, it does not directly affect the safe administration of morphine. Fever is not an immediate contraindication to opioid use.
B. Heart rate: Heart rate should be monitored, but morphine primarily depresses the respiratory system rather than significantly affecting heart rate in most cases.
C. Respiratory rate: Morphine can cause respiratory depression, especially in opioid-naive or older adults. Assessing the respiratory rate before administration ensures the client can safely tolerate the medication and allows for early detection of adverse effects.
D. Blood pressure: Morphine can cause hypotension, so blood pressure monitoring is important, but respiratory depression poses a more immediate life-threatening risk and takes priority before administration.
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.
