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 B
Explanation
A) "I will offer my child apple juice instead of milk.": Offering apple juice instead of milk is not ideal for a toddler with failure to thrive. Milk is a better source of essential nutrients like calcium and vitamin D, which are important for growth and development. Juice can contribute to empty calories and should be limited.
B) "I should continue to feed my child when he pushes food out with his tongue.": This statement indicates an understanding of the importance of addressing feeding difficulties. In toddlers with Down syndrome, it is common to experience difficulties with feeding and swallowing. Continuing to offer food and using techniques to encourage eating, even when the child initially pushes food out, can help ensure adequate nutritional intake and support growth.
C) "I will provide his favorite food as a reward for good behavior.": Using food as a reward can lead to unhealthy eating habits and an association of food with behavior rather than hunger and nutrition. It’s better to use non-food rewards to encourage positive behavior.
D) "I should increase my child's vitamin A intake by feeding him raw carrot slices.": While vitamin A is important, raw carrots can be difficult for toddlers, especially those with developmental delays or oral-motor difficulties, to chew and swallow. Cooked carrots or other vitamin A-rich foods might be a safer option.
Correct Answer is A
Explanation
A) Talk about the special features of the baby with the client: This intervention acknowledges the baby as a real person and can provide comfort to the grieving parents by validating their loss and giving them a chance to create memories, which is an important aspect of the grieving process.
B) Post a sign indicating No Visitors: This may not be appropriate as it might isolate the client further. Some parents may want the support of family and friends during this difficult time, and such a restriction should be based on the parents' wishes rather than a standard protocol.
C) Limit the amount of time the client is allowed to have the baby in her room: Allowing parents to spend as much time as they need with their baby can help them with the grieving process. Placing limits might be perceived as insensitive and could hinder the emotional healing process.
D) Tell the parents they should hold their baby: While many parents find comfort in holding their stillborn baby, it should be offered as a choice rather than a directive. It is important to respect the parents' individual coping mechanisms and provide support based on their preferences.
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