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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A) Bounding peripheral pulses: Metabolic acidosis typically does not cause bounding peripheral pulses. In metabolic acidosis, vasodilation might occur, but it usually leads to weaker, not bounding, pulses due to decreased cardiac output and blood pressure.

B) Hyperreflexia: Hyperreflexia is not commonly associated with metabolic acidosis. Instead, metabolic acidosis may cause symptoms like muscle weakness or fatigue due to the effect of acid-base imbalance on neuromuscular function.

C) Cool skin: While cool skin can sometimes be associated with poor perfusion in severe cases, it is not a direct manifestation of metabolic acidosis. Metabolic acidosis more commonly affects internal physiology rather than peripheral skin temperature directly.

D) Hypotension: Hypotension is a common manifestation of metabolic acidosis. The acidosis leads to vasodilation and decreased cardiac contractility, resulting in a drop in blood pressure. This is a critical sign for the nurse to monitor as it indicates the severity of the acid-base imbalance and its effect on the cardiovascular system.

A. "Monitor for manifestations of hypoglycemia." B. "Take this medication at bedtime." C. "Weigh yourself weekly to monitor for weight loss." D. "Plan to continue to take over-the-counter medications as needed."

Correct Answer is A

Explanation

A) "Monitor for manifestations of hypoglycemia":
Glipizide is a sulfonylurea, which works by increasing insulin secretion from the pancreas. This can lower blood glucose levels, potentially leading to hypoglycemia. Therefore, it's essential for the client to be aware of and monitor for symptoms such as sweating, shakiness, confusion, and dizziness to manage and treat hypoglycemia promptly.

B) "Take this medication at bedtime":
Glipizide is typically taken before meals to stimulate insulin secretion in response to food intake, helping control postprandial blood glucose levels. Taking it at bedtime is not recommended as it might not be as effective and could increase the risk of nighttime hypoglycemia.

C) "Weigh yourself weekly to monitor for weight loss":
While weight monitoring is important for managing diabetes, glipizide does not commonly cause weight loss. In fact, it may sometimes lead to weight gain. Therefore, this instruction is less relevant than monitoring for hypoglycemia.

D) "Plan to continue to take over-the-counter medications as needed":
Over-the-counter medications can interact with glipizide, potentially affecting blood glucose levels or increasing the risk of side effects. The client should consult with their healthcare provider before taking any new medications. This instruction does not address the primary concern of hypoglycemia management.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has acute kidney failure and is in a state of metabolic acidosis. The nurse should monitor for which of the following manifestations?

Correct Answer is D

Explanation

A nurse is teaching a client who has type 2 diabetes mellitus about a new prescription for glipizide. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 31 weeks of gestation and has gestational diabetes mellitus. The client asks, "Can gestational diabetes affect my baby?" Which of the following responses should the nurse make?

A nurse is reviewing a client's laboratory results. The client's ABGS are as follows: pH 7.6, HCO3 24 mEq/L, PaCO2 30 mm Hg, PaO2 90 mm Hg. Which of the following acid-base imbalances should the nurse identify the client is experiencing?

A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of the prostate to treat benign prostatic hypertrophy. The client has an indwelling urinary catheter. Which of the following findings should the nurse report to the provider immediately?

A nurse is examining a skin infection on a client's lower left leg. Findings include edema, erythema, tenderness, and the client reports pain. The nurse should identify that these findings indicate which of the following?

A nurse in an emergency department is caring for a preschooler who experienced a near drowning and has hypothermia. Which of the following actions should the nurse take?

A nurse is providing discharge teaching to a female client who has the communicable disease herpes simplex virus II. Which of the following instructions should the nurse include in the teaching?

A nurse is planning care for a client who is postoperative following a lithotripsy for renal calculi. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

A nurse is assessing a client who has hypothermia. Which of the following findings should the nurse identify as a manifestation of hypothermia?