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 ["A","B","C","D"]

Explanation

A. Amount of time washing hands: The client increased handwashing time to 15 seconds, which meets the CDC’s recommended minimum for effective hand hygiene when preparing food.

B. Use of cutting board: The client now uses separate cutting boards for raw meats and raw vegetables, which helps prevent cross-contamination and foodborne illness.

C. Defrosting of frozen foods: Defrosting foods in the refrigerator is a safe method that prevents bacterial growth, unlike leaving food on the countertop.

D. Leftover storage time in refrigerator: Storing leftovers in the refrigerator for a maximum of 2 days (or 7 days initially) demonstrates proper food handling to prevent spoilage and bacterial growth.This aligns with recommended guidelines.

E. Refrigerator temperature: Although the temperature has improved (now 5.6°C instead of 6.7°C), the ideal refrigerator temperature should be 4°C (40°F) or lower for optimal food safety.

F. Time leftovers sit unrefrigerated on countertop: Leaving leftovers at room temperature for 2 hours still meets the maximum allowable limit, but best practice is to refrigerate within 1 hour if the room temperature is high (above 90°F/32°C), which might not reflect consistent safe food handling in all conditions.

A. Impaired hearing B. Reduced health literacy C. Lower extremity weakness D. Texting while driving

Correct Answer is D

Explanation

A. Impaired hearing: Impaired hearing can increase the risk of injury by reducing the client’s ability to hear alarms or warnings. However, it is considered a sensory impairment rather than a lifestyle choice.

B. Reduced health literacy: Low health literacy can contribute to poor understanding of safety instructions and adherence to precautions, increasing injury risk. Nonetheless, it relates more to knowledge deficits than lifestyle behaviors.

C. Lower extremity weakness: Weakness in the legs increases fall risk due to impaired mobility and balance. This is a physical or functional risk factor rather than a lifestyle risk.

D. Texting while driving: Texting while driving is a high-risk lifestyle behavior directly associated with increased injury and accident rates. It involves voluntary behavior that compromises safety and is a preventable cause of injury.

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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","B","C","D"]

Explanation

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Correct Answer is D

Explanation

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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.