A nurse is assisting in the care of a client who is scheduled for an appendectomy.

Exhibits
The nurse is assisting with preparing the client for surgery. Select the 3 findings that require follow-up prior to surgery.

Dietary intake

Pain level

Blood pressure

Informed consent

Oxygen saturation

Allergies

Answer and Explanation

Correct Answer : A,B,F

A. Dietary intake: The client ate toast at 0600 and experienced vomiting. Since general anesthesia is typically used for an appendectomy, recent food intake increases the risk of aspiration and should be reported immediately to the surgical team.

B. Pain level: The client reports increasing pain (now 8/10) with rebound tenderness. This may indicate worsening inflammation or risk of rupture, which requires reassessment and potentially expedited surgical intervention.

C. Blood pressure: The blood pressure of 124/80 mm Hg is within normal limits and does not require follow-up before surgery. It reflects stable hemodynamics.

D. Informed consent: The provider has already obtained informed consent and placed it in the medical record. No further follow-up is needed unless the client withdraws consent or shows signs of confusion.

E. Oxygen saturation: The client's oxygen saturation is 96% on room air, which is acceptable. There are no indications of respiratory compromise that require further intervention preoperatively.

F. Allergies: The client reports allergies to shellfish, latex, and penicillin. These pose serious risks during surgery (e.g., anaphylaxis to latex gloves or antibiotics) and must be addressed in the preoperative checklist to ensure appropriate substitutes are used.

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Correct Answer is C

Explanation

A. "I'll use focused breathing to control my pain." Focused breathing is a relaxation technique, but it is distinct from guided imagery. Guided imagery specifically involves creating vivid mental pictures to distract and soothe the mind.

B. "I'll listen to my favourite music to take my mind off the pain." Listening to music is a form of distraction or music therapy, which can help with pain management but is different from guided imagery, which relies on mental visualization.

C. "I'll think about my grandfather's farm to reduce pain." This statement reflects guided imagery, where the client mentally pictures a peaceful, pleasant scene to divert attention from pain and promote relaxation, showing understanding of the technique.

D. "I'll learn to notice the sensation of muscle tension." Noticing muscle tension is related to mindfulness or biofeedback, focusing on awareness of bodily sensations rather than the visualization involved in guided imagery.

A. Brittle hair B. Yellow conjunctivae C. Bradycardia D. Clubbing of the fingernails

Correct Answer is A

Explanation

A. Brittle hair: Malnutrition often leads to protein and micronutrient deficiencies, which impair hair growth and texture, resulting in dry, brittle, or thinning hair. This is a common visible sign in clients with poor nutritional status.

B. Yellow conjunctivae: Yellowing of the conjunctivae typically indicates jaundice due to liver dysfunction or hemolysis, not malnutrition from inflammatory bowel disease. It reflects bilirubin accumulation rather than nutrient deficiency.

C. Bradycardia: While bradycardia may occur in severe starvation or electrolyte imbalance, it is not a consistent or early indicator of malnutrition from inflammatory bowel disease. It requires further context to be clinically relevant.

D. Clubbing of the fingernails: Clubbing is associated with chronic hypoxia or pulmonary/cardiac conditions. It is not commonly linked to malnutrition or inflammatory bowel disease unless there are severe complications such as chronic anemia or hypoxia.

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A nurse is assisting in the care of a client who is scheduled for an appendectomy. Exhibits The nurse is assisting with preparing the client for surgery. Select the 3 findings that require follow-up prior to surgery.

Nursing Test Bank

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Correct Answer is A

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A nurse is assisting in the care of a client who is scheduled for an appendectomy.

Exhibits
The nurse is assisting with preparing the client for surgery. Select the 3 findings that require follow-up prior to surgery.