A client admitted with appendicitis who is scheduled for surgery in 2 hours complains of increased abdominal pain, vomiting, distended abdomen, and diminished bowel sounds. What is the most appropriate nursing intervention?

Administer a laxative to promote bowel movement

Offer the client pain medication

Assist the client to ambulate in the hallway

Notify the healthcare provider immediately

Answer and Explanation

The Correct Answer is D

A. Administer a laxative to promote bowel movement: Laxatives are contraindicated - they increase bowel motility and could precipitate perforation or worsen obstruction/peritonitis in an acute abdomen.

B. Offer the client pain medication: Analgesia is important but not the priority if the client shows signs of worsening/complication (increasing pain, distention, vomiting). Masking worsening signs without prompt evaluation could be harmful. Pain meds may be given after notifying the provider and as ordered.

C. Assist the client to ambulate in the hallway: Ambulation is inappropriate for a client with a potentially worsening acute abdominal process (risk of perforation, hemodynamic instability, or sudden deterioration). It could increase discomfort and risk.

D. Notify the healthcare provider immediately: These signs suggest possible complication (perforation, bowel obstruction, or peritonitis). Immediate notification allows urgent reassessment and possible expediting of surgery or additional interventions - this is the most appropriate immediate action.

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Correct Answer is B

Explanation

A. "A hiatal hernia might increase your risk for intestinal cancer."Hiatal hernias are not associated with an increased risk of intestinal (colon) cancer.

B. "A hiatal hernia might increase your risk for GERD."A hiatal hernia allows part of the stomach to move into the thoracic cavity, which can cause gastroesophageal reflux due to weakened lower esophageal sphincter pressure.

C. "A hiatal hernia might increase your risk for stomach cancer."Hiatal hernias do not directly increase the risk of gastric cancer. The main complication is reflux esophagitis, not malignancy.

D. "A hiatal hernia might increase your risk for lung disease."While chronic reflux can occasionally cause aspiration and pulmonary symptoms, hiatal hernia is not a direct risk factor for lung disease.

A. Review stress factors that can cause disease exacerbation. B. Promote physical mobility. C. Provide emotional support. D. Evaluate fluid and electrolyte levels.

Correct Answer is D

Explanation

A. Review stress factors that can cause disease exacerbation:Stress management is important for long-term care but does not address immediate physiologic needs during an acute flare.

B. Promote physical mobility: Mobility is beneficial for overall health, but it is not the highest priority during acute exacerbations where fluid and electrolyte imbalances are urgent.

C. Provide emotional support:Emotional support is important, but it does not take precedence over life-sustaining interventions during acute illness.

D. Evaluate fluid and electrolyte levels:Clients with ulcerative colitis exacerbations are at risk of severe dehydration and electrolyte imbalances due to diarrhea. Monitoring and correcting these imbalances takes precedence over other interventions.

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A client admitted with appendicitis who is scheduled for surgery in 2 hours complains of increased abdominal pain, vomiting, distended abdomen, and diminished bowel sounds. What is the most appropriate nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has recently been diagnosed with a hiatal hernia. Which of the following new information will be beneficial for the nurse to relay to the client?

Correct Answer is B

Explanation

A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority?

Correct Answer is D

Explanation

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