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. Tell the client to think about something else: Redirecting the client's thoughts without addressing their emotional distress can be dismissive. It does not support emotional processing or help the nurse assess the client’s coping needs.

B. Tell the client that everything will be okay: Offering false reassurance minimizes the client’s feelings and may hinder open communication. It does not validate their experience or help develop coping strategies.

C. Ask the client to describe their support system: Exploring the client’s support system helps assess available emotional and practical resources. This information is essential in planning appropriate interventions and enhancing coping capacity.

D. Ask the client why they're unable to cope: "Why" questions can make clients feel defensive and judged. It is more therapeutic to use open-ended questions that invite sharing without implying blame.

A. Explain that the treatment is both safe and therapeutic. B. Tell the client that the procedure is necessary. C. Notify the client's loved ones of the client's refusal of the procedure. D. Inform the client they have the right to refuse treatment.

Correct Answer is D

Explanation

A. Explain that the treatment is both safe and therapeutic: Providing reassurance about the safety and effectiveness of the procedure may be informative, but it can unintentionally pressure the client to consent. It does not respect the client’s autonomy or support their right to make independent healthcare decisions.

B. Tell the client that the procedure is necessary: Telling the client a procedure is necessary can sound coercive and may disregard their legal and ethical right to refuse treatment. Nurses must prioritize respecting the client's decisions, even if those decisions involve refusing recommended medical care.

C. Notify the client's loved ones of the client's refusal of the procedure: Informing family members without the client’s consent may breach confidentiality and is not appropriate unless the client is unable to make informed decisions. Client autonomy must be preserved, and their refusal should be respected unless there is an immediate risk of harm.

D. Inform the client they have the right to refuse treatment: Clients have the legal and ethical right to refuse any medical intervention, even if it is life-sustaining. The nurse’s role includes advocating for the client’s autonomy, ensuring informed consent, and supporting their decision without judgment or pressure.

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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.

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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.