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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Orthostatic hypotension:
Tamsulosin, an alpha-blocker used to treat benign prostatic hypertrophy, can cause orthostatic hypotension, which is a significant adverse effect. This condition involves a sudden drop in blood pressure when standing up, leading to dizziness or fainting. It's important for clients to report these symptoms to their healthcare provider for potential adjustment of medication or additional instructions on managing this side effect.
B) Muscle tenderness:
Muscle tenderness is not commonly associated with tamsulosin. While muscle pain can occur with other medications, it is not a known adverse effect of tamsulosin and does not require immediate notification to the provider in the context of this medication.
C) Decreased heart rate:
Tamsulosin does not typically cause bradycardia (decreased heart rate). This side effect is more associated with beta-blockers or other cardiac medications, rather than alpha-blockers like tamsulosin. Reporting this would be relevant for those other medications but not for tamsulosin.
D) Oliguria:
Oliguria, or decreased urine output, is not a known adverse effect of tamsulosin. Tamsulosin helps improve urine flow in clients with benign prostatic hypertrophy, so reporting oliguria would not be pertinent in this context. Instead, it could indicate another underlying issue.
Correct Answer is A
Explanation
A) Orthostatic hypotension: Anemia often results in decreased blood volume and oxygen-carrying capacity, which can cause orthostatic hypotension. This condition is characterized by a sudden drop in blood pressure when moving from a sitting or lying position to standing, leading to dizziness or fainting.
B) Clubbing of the nail beds: Clubbing is typically associated with chronic hypoxia and long-term respiratory or cardiovascular diseases, rather than anemia. It involves the enlargement of the fingertips and changes in the angle of the nail bed.
C) Conjunctivitis: Conjunctivitis is an inflammation of the conjunctiva, usually caused by infections, allergies, or irritants. It is not a common manifestation of anemia.
D) Heat intolerance: Heat intolerance is more commonly associated with hyperthyroidism or other metabolic disorders rather than anemia. Individuals with anemia are more likely to experience cold intolerance due to reduced oxygen delivery to tissues.
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