A nurse in an emergency department is caring for a client who has appendicitis. Which of the following actions should the nurse take?
Maintain the client in a semi-Fowler's position.
Administer an enema 1 hr prior to surgery.
Apply a warm pack to the client's lower abdomen.
Place the client on a clear liquid diet.
The Correct Answer is A
Choice A rationale:
The nurse should maintain the client in a semi-Fowler's position to promote comfort and reduce the risk of complications related to appendicitis. This position helps to decrease pressure on the abdomen and may alleviate pain by reducing tension on the abdominal muscles.
Choice B rationale:
Administering an enema 1 hour prior to surgery is not indicated for a client with appendicitis. Enemas are generally not recommended for clients with suspected or confirmed appendicitis as they can potentially worsen inflammation and cause perforation of the inflamed appendix.
Choice C rationale:
Applying a warm pack to the client's lower abdomen is contraindicated in appendicitis. Heat can exacerbate inflammation and should be avoided in such cases.
Choice D rationale:
Placing the client on a clear liquid diet is not appropriate for appendicitis. Clients with appendicitis are typically NPO (nothing by mouth) to avoid stimulating the gastrointestinal tract and reduce the risk of rupture if surgery is needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale:
While wearing a protective gown is essential to minimize exposure to bodily fluids and to ensure the nurse's protection, it is not specifically aimed at decreasing the risk for ventilator-associated pneumonia (VAP). The key interventions to prevent VAP focus on maintaining airway hygiene and proper positioning, not just personal protective equipment during suctioning.
Choice B rationale:
Monitoring oral secretions every 2 hours is an important strategy in reducing the risk of VAP. Accumulation of secretions in the mouth and upper airway can promote bacterial growth, increasing the risk of aspiration and infection. By regularly assessing and removing secretions, the nurse can reduce the chances of bacteria being aspirated into the lungs and causing pneumonia.
Choice C rationale:
Oral care every 2 hours is a critical intervention to reduce the risk of VAP. Mechanical ventilation predisposes clients to the growth of bacteria in the oral cavity, and poor oral hygiene increases the risk of oral bacteria being aspirated into the lungs. Regular oral care, including brushing teeth, gums, and the tongue, as well as using antiseptic solutions, helps reduce the microbial load in the mouth and decreases the risk of VAP.
Choice D rationale:
Maintaining a client in a supine position is not recommended for preventing VAP. The best practice is to maintain the head of the bed elevated at a 30-45 degree angle (semi-Fowler's position) to reduce the risk of aspiration. A supine position increases the likelihood of gastric contents or secretions being aspirated into the lungs, which can lead to VAP.
Choice E rationale:
Assessing the client daily for readiness for extubation is an essential practice in preventing VAP. The longer a patient remains intubated, the higher the risk of developing VAP due to prolonged exposure of the endotracheal tube in the airway. Regular assessment for extubation helps to ensure that the client is appropriately weaned off the ventilator as soon as they are stable, reducing the risk of VAP and other complications associated with prolonged ventilation.
Correct Answer is C
Explanation
Answer: C. "Insert the entire needle into your skin to administer medication completely."
Rationale:
A) "Administer this medication into your leg muscle."
Enoxaparin should be administered subcutaneously, typically in the abdominal area, not into a muscle. Injecting it intramuscularly can lead to unpredictable absorption and increase the risk of bleeding.
B) "Expel the excess air in the syringe before you administer the medication."
This statement is incorrect. For enoxaparin, it is recommended to retain the air bubble in the syringe. The air bubble helps ensure the entire dose is delivered and minimizes leakage at the injection site.
C) "Insert the entire needle into your skin to administer medication completely."
This is an appropriate instruction as it emphasizes the need to fully insert the needle for effective subcutaneous delivery of enoxaparin. Proper technique is essential to ensure the medication is administered as intended.
D) "Take ibuprofen for fever following administration of this medication."
This recommendation is not advisable because ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), can increase the risk of bleeding, especially when taken concurrently with enoxaparin. The client should consult their healthcare provider for safe alternatives for managing fever or pain.
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