A nurse is caring for a client who is scheduled for an appendectomy.
Exhibit 1 Exhibit 2 Exhibit 3
Nurses' Notes
1050:
Received handoff report from the ED nurse for a client who has acute appendicitis and is scheduled for an appendectomy. Client reports that pain began in the midabdominal region during the night. This morning the pain intensified and localized to the right lower quadrant region. Pain continues to intensify. rebound tenderness noted. Reports vomiting one time after eating a piece of toast at 0600 with continued feelings of nausea.
Peripheral IV to the left forearm with IV fluids infusing.
1200:
Informed consent obtained by the surgeon performing the procedure. Placed in the client's medical record. Client expressing concern about potential complications that could result from the surgery.
Medical History
1050:
Received influenza vaccine 1 month ago.
Thyroid disease, taking levothyroxine for 14 years. History of cholecystectomy 3 years ago.
Denies alcohol or illegal drug use. Reports smoking approximately 6 cigarettes per day for the past 10 years. Allergic to shellfish, latex, and penicillin.
Vital Signs
0945, Upon admission to emergency department (ED): Temperature 38.3°C(100.9° F)
Pulse rate 102/min Respiratory rate 22/min
Blood pressure 122/80 mm Hg Oxygen saturation 96% on room air Pain reported as 6 on a scale of 0 to 10.
1050, Upon admission to medical-surgical department Temperature 38,4° C (101.2° F)
Pulse rate 104/min Respiratory rate 22/min
Blood pressure 124/80 mm Hg Oxygen saturation 96% on room air Pain reported as 8 on a scale of 0 to 10
The nurse is preparing the client for surgery. Select the 4 findings that require follow-up prior to surgery.
Dietary intake
Oxygen saturation
Pain level
Blood pressure
Allergies
Informed consent
Correct Answer : A,C,E,F
A. The nurse asks the client when was the last time they ate or drank anything, and verifies that they are fasting according to the preoperative instructions. Dietary intake is important because the client should have an empty stomach to prevent aspiration during anesthesia.
B. The oxygen saturation remains at 96% on room air, which is within the normal range. No immediate follow-up is needed based on this parameter.
C. The client's pain level has increased from 6 to 8 on a scale of 0 to 10. This increase in pain intensity requires further assessment and intervention to ensure adequate pain management before surgery.
D. The client's blood pressure remains relatively stable within normal limits.
However, the increase in pain intensity may impact blood pressure, and it's essential to monitor for any significant changes.
E. The allergies are important to identify because the client is allergic to shellfish, latex, and penicillin, which could cause anaphylaxis or other adverse reactions during surgery or anesthesia. The nurse should ensure that the client is wearing an allergy bracelet and that the surgical team is aware of the allergies.
F. The informed consent is essential to obtain before any invasive procedure. The nurse should verify that the client understands the risks, benefits, and alternatives of the surgery and that the consent form is signed and witnessed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Using the room number to identify a patient is not reliable since many clients may share it.
B. The telephone number is not typically used for client identification during assessments.
C. The nurse should use the client's name to properly identify the client before performing any assessment or intervention. This is a standard safety measure that helps to prevent errors and ensure quality care.
D. The diagnosis is important for providing appropriate care but is not used for client identification during assessments.
Correct Answer is D,E,C,B,A
Explanation
A. Deep palpation is the final step in an abdominal examination since it may elicit tenderness which may interfere with other aspects of examination.
B. This is the second last step just before deep palpation. It is used to detect any obvious masses or areas of tenderness.
C. Percussion is the third step in an abdominal examination where the nurse should percuss the client's abdomen systematically, tapping lightly on each area and noting the sound quality. It can be used to detect the presence of ascites which be stony dull on percussion.
D. Inspection is the first step where the nurse should inspect the contours of the client's abdomen using a penlight, looking for any abnormalities or distension.
E. Auscultation is the second step in an abdominal examination. The nurse should auscultate the client's abdomen using the diaphragm of the stethoscope, listening for bowel sounds in all four quadrants.
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