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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Related Questions
Correct Answer is B
Explanation
A) Place the client in a semi-Fowler's position:
While positioning can be beneficial for various conditions, it does not directly address the core issue of hypothermia. Rewarming the client effectively is the primary concern in hypothermia management.
B) Infuse warm IV fluids:
Administering warm IV fluids is a crucial intervention for moderate hypothermia as it helps increase the client's core body temperature more rapidly and effectively. This method ensures that the body's internal temperature is raised, which is vital for stabilizing the client.
C) Assess the client's skin hourly when using a heating blanket:
Monitoring the skin is important to prevent burns or skin damage from a heating blanket, but it is a supportive measure rather than a primary intervention. The key priority is to rewarm the client’s core.
D) Rewarm the client's extremities first:
Rewarming the extremities first can actually be harmful in hypothermia, as it can lead to a drop in core body temperature due to the return of cold blood from the periphery to the core (afterdrop). The focus should be on warming the core body first.
Correct Answer is B
Explanation
A. Apply dry heat to help the lesions scab over.: Applying dry heat is not a recommended treatment for herpes simplex lesions. Moist heat, such as sitz baths, can help alleviate discomfort and promote healing.
B. Take three sitz baths each day to alleviate symptoms.: Sitz baths can help soothe and clean the affected area, providing relief from pain and itching associated with herpes simplex virus lesions. This is an appropriate recommendation for symptom management.
C. Apply talcum powder to the perineal area to help the lesions dry.: Talcum powder is not recommended for herpes simplex lesions as it can irritate the skin and worsen symptoms. Keeping the area dry can be beneficial, but using powders is not advised.
D. You can resume intercourse with the use of natural membrane condoms.: Condoms may reduce the risk of transmission but do not eliminate it completely. It is generally advised to avoid sexual activity during an outbreak to prevent spreading the virus.
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