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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "Sit with your legs in a dependent position when in a chair."
Sitting with legs in a dependent position can decrease blood flow and increase the risk of clot formation. It's important to elevate the legs when sitting to promote venous return and reduce the risk of deep-vein thrombosis (DVT).
B) "Prevent dehydration by drinking at least 2.5 liters fluids each day."
Staying well-hydrated helps maintain good blood circulation and prevents blood from becoming too viscous, reducing the risk of clot formation. Adequate fluid intake is crucial in preventing DVT.
C) "Massage your calves after sitting for 2 hours."
Massaging the calves is not recommended for someone with a history of DVT, as it may dislodge a clot. Instead, clients should be encouraged to move or stretch their legs regularly to improve circulation.
D) "Roll stretchy nylon stockings down to the upper part of your calves."
Proper use of compression stockings involves wearing them as prescribed, which typically means keeping them fully extended to ensure consistent pressure along the leg. Rolling them down can create a tourniquet effect and is not recommended.
Correct Answer is D
Explanation
A) Dyspepsia:
Dyspepsia, or indigestion, is a common symptom of peptic ulcer disease, causing discomfort in the upper abdomen. While it is uncomfortable and should be managed, it is not immediately life-threatening and does not require urgent intervention compared to other symptoms.
B) Nausea:
Nausea can be a distressing symptom associated with peptic ulcer disease, often resulting from irritation of the stomach lining. Although it can significantly impact the client’s well-being and appetite, it is not as critical as symptoms indicating active bleeding or more severe complications.
C) Hyperactive bowel sounds:
Hyperactive bowel sounds may be present in peptic ulcer disease due to increased gastrointestinal activity. This finding suggests heightened digestive activity but does not indicate an immediate life-threatening condition that would take precedence over signs of active bleeding.
D) Hematemesis:
Hematemesis, or vomiting blood, is a serious and potentially life-threatening symptom that indicates active gastrointestinal bleeding. This requires immediate medical attention to prevent significant blood loss, shock, and other complications. It is the priority finding because it poses the most immediate risk to the client’s health and stability.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.