A nurse in an emergency department is caring for a client who has suspected appendicitis. Which of the following actions should the nurse plan to take?

Monitor the client for an elevated RBC count.

Instruct the client to not eat food or drink liquids.

Administer an enema to the client.

Maintain the client in a supine position.

Answer and Explanation

The Correct Answer is B

A. Monitor the client for an elevated RBC count.: While an elevated white blood cell count (WBC) is more indicative of appendicitis, an elevated RBC count is not typically used to diagnose appendicitis.

B. Instruct the client to not eat food or drink liquids.: This is important as it prepares the client for a potential surgical procedure. If the appendix is inflamed and surgery is necessary, the client should not eat or drink to prevent complications related to anesthesia and surgery.

C. Administer an enema to the client.: Administering an enema is not recommended as it can increase the risk of perforation of the appendix, which is a serious complication.

D. Maintain the client in a supine position.: While maintaining a supine position may be necessary, it is not as critical as ensuring the client remains NPO (nil per os) in preparation for possible surgery. The position is less of a priority compared to dietary restrictions in this scenario.

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Correct Answer is C

Explanation

A) "Gestational diabetes increases the risk of your baby having hemorrhagic disease after birth." Hemorrhagic disease of the newborn is typically related to vitamin K deficiency, not gestational diabetes. Thus, this response does not directly address the risks associated with gestational diabetes.

B) "Gestational diabetes increases the risk of your baby having a cleft lip or palate." Cleft lip and palate are congenital conditions that are more related to genetic and environmental factors during the early stages of pregnancy. Gestational diabetes does not increase the risk of these specific congenital abnormalities.

C) "Gestational diabetes increases the risk of your baby having hypoglycemia after birth." This is correct. Infants born to mothers with gestational diabetes are at risk for hypoglycemia shortly after birth due to the high levels of insulin produced in response to maternal hyperglycemia during pregnancy.

D) "Gestational diabetes increases the risk of your baby having a low birth weight." Gestational diabetes more commonly leads to macrosomia (large birth weight) rather than low birth weight. The excessive glucose levels in the mother’s blood can result in increased fetal insulin production, leading to increased growth and fat deposits.

A. Discontinue the overhead trapeze. B. Turn the client every 6 hr while in bed. C. Remind the client that phantom limb pain does not need treatment. D. Assist the client to a prone position every 3 hr.

Correct Answer is D

Explanation

A) Discontinue the overhead trapeze:
The overhead trapeze can be beneficial for the client to assist with repositioning and mobility, especially postoperatively. Removing it would hinder the client's ability to move independently and could increase the risk of complications from immobility.

B) Turn the client every 6 hr while in bed:
Turning the client every 6 hours is insufficient for preventing complications such as pressure ulcers. Standard care involves repositioning the client at least every 2 hours to maintain skin integrity and promote circulation.

C) Remind the client that phantom limb pain does not need treatment:
Phantom limb pain is a real and often distressing condition for many amputees. It requires appropriate treatment and management strategies to ensure the client's comfort and psychological well-being. Dismissing the pain can lead to increased distress and hinder recovery.

D) Assist the client to a prone position every 3 hr:
Positioning the client in a prone position regularly helps prevent contractures, particularly hip flexion contractures, which are common after lower limb amputations. This position can stretch the hip muscles and aid in maintaining proper alignment and mobility, making it a beneficial intervention in postoperative care.

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A nurse in an emergency department is caring for a client who has suspected appendicitis. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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