A nurse is assisting in the care of a client who is scheduled for an appendectomy.
Dietary intake
Pain level
Blood pressure
Informed consent
Oxygen saturation
Allergies
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increase in protein requirements: Protein needs may slightly increase with age to maintain muscle mass, but this does not directly cause weight gain. Instead, inadequate protein may contribute to muscle loss.
B. Increase in fluid requirements: Older adults typically have decreased thirst sensation, not increased fluid needs. Weight gain is not directly linked to hydration needs but more to energy balance.
C. Decrease in vitamin intake: While older adults may have reduced vitamin intake due to dietary changes, this affects micronutrient status rather than causing significant weight gain.
D. Decrease in muscle mass: Sarcopenia, the loss of muscle mass with aging, lowers basal metabolic rate. This decreases calorie expenditure, making it easier to gain weight even with unchanged food intake.
Correct Answer is ["B","A","C","D"]
Explanation
A. Check the client's gastric residual: After confirming tube placement, gastric residual is assessed to evaluate delayed gastric emptying, which could increase the risk of aspiration. This is done before administering medications or feedings.
B. Verify the tube placement: Tube placement is verified first to ensure the medication is delivered into the stomach and not the lungs. This prevents aspiration and other complications associated with incorrect tube placement.
C. Pour the medication into the syringe and allow it to flow by gravity: Once placement is confirmed and residual checked, the medication is administered via gravity through the syringe to minimize pressure on the NG tube and promote safe delivery.
D. Clamp the NG tube for 20 to 30 min: After administering the medication, the NG tube is clamped to allow for medication absorption before suction is resumed. Immediate suctioning would remove the medication before it can take effect.
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