A client with suspected appendicitis is waiting for surgery. What should the nurse do?

Offer the client a warm beverage.

Monitor the client's gag reflex.

Help the client to a side-lying position with knees flexed.

Bring the client a heating pad to apply to the abdomen for comfort.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Offering a warm beverage to a client with suspected appendicitis is not advisable. Preoperative clients are typically required to have an empty stomach to reduce the risk of aspiration during anesthesia. Introducing fluids or food could delay surgery and increase the risk of complications.

Choice B reason:

Monitoring the client's gag reflex is not a priority in the care of a client with suspected appendicitis. The gag reflex is more relevant in neurological assessments or when evaluating swallowing function, not in the context of appendicitis.

Choice C reason:

Helping the client to a side-lying position with knees flexed can provide comfort and may help relieve abdominal pain. This position reduces tension on the abdominal muscles and can be a supportive measure while the client awaits surgery.

Choice D reason:

Applying a heating pad to the abdomen is contraindicated in clients with suspected appendicitis. Heat can cause the appendix to rupture, leading to peritonitis, which is a severe and potentially life-threatening complication. Therefore, this action should be avoided.

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Correct Answer is B

Explanation

Choice A Reason:
Asking the client to share the joke may imply that the nurse believes the client is laughing at a joke, which may not be the case. It's important to recognize that uncontrollable laughter can be a symptom of schizophrenia and not necessarily a response to humor.

Choice B Reason:
This response is open-ended and nonjudgmental, inviting the client to explain their behavior without making assumptions. It allows the client to share their experience, which could be related to an internal stimulus such as a hallucination or simply a response they cannot control.

Choice C Reason:
Asking "Why are you laughing?" could be perceived as confrontational or accusatory. It might make the client feel defensive or misunderstood, especially if the laughter is a symptom of their condition and not something they are doing voluntarily.

Choice D Reason:
Saying "I don't think I said anything funny" focuses on the nurse's perspective rather than the client's experience. It could inadvertently dismiss the client's behavior as inappropriate or unjustified, which is not supportive in a therapeutic relationship.

A. Cyanosis noted in nail beds bilaterally. B. Lungs clear to auscultation. C. Inability to speak in full sentences. D. Pulse oximetry 94-96% on room air.

Correct Answer is ["B","D"]

Explanation

Choice A reason:
Cyanosis, or a bluish discoloration of the skin, particularly in the nail beds, is a sign of inadequate oxygenation and would not indicate successful intervention. The absence of cyanosis would be a positive outcome, reflecting improved oxygen saturation.

Choice B reason:
Lungs clear to auscultation would indicate that air is moving through all regions of the lungs without obstruction from fluid or mucus, which is a sign of recovery from pneumonia. This finding suggests that the interventions aimed at improving gas exchange, such as positioning, deep breathing exercises, and suctioning if needed, have been effective.

Choice C reason: The inability to speak in full sentences often indicates respiratory distress and would not be a sign of successful nursing intervention. An improvement would be the client's ability to speak in full sentences without difficulty, reflecting better lung function and gas exchange.

Choice D reason:
Pulse oximetry readings between 94-96% on room air are within normal limits and indicate adequate oxygen saturation and gas exchange. This is a clear sign that the client's respiratory status has improved, and the interventions for Impaired Gas Exchange have been successful.

Choice E reason:
Bronchovesicular breath sounds are normal breath sounds heard over the major bronchi and are typically moderate in pitch and intensity. However, they are not specifically indicative of successful intervention for Impaired Gas Exchange. The absence of abnormal sounds such as crackles or wheezes would be more relevant.

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A client with suspected appendicitis is waiting for surgery. What should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is sitting with a client diagnosed with schizophrenia, who starts to laugh uncontrollably, although the nurse has not said anything funny. The nurse should say:

Correct Answer is B

Explanation

A nurse implements a plan of care for a client with the problem of Impaired Gas Exchange as a result of left lower lobe pneumonia. Which findings would indicate that nursing interventions were successful? (Select all that apply)

Correct Answer is ["B","D"]

Explanation

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