A nurse is contributing to the plan of care for an adolescent client following surgery for a ruptured appendix. Which of the following interventions should the nurse recommend to include in the plan?
Encourage the client to change positions every 4 hr.
Offer the client a clear liquid diet when fully alert.
Ensure that the client receives pain medication prior to ambulation.
Discontinue antibiotic therapy on the first postoperative day.
The Correct Answer is C
A. Encourage position change every 4 hr
Should be more frequent, typically every 2 hr to prevent complications.
B. Offer clear liquids when fully alert
Bowel sounds and flatus should be confirmed first to avoid ileus.
C. Ensure the client receives pain medication prior to ambulation.
Adequate pain control promotes mobility and reduces complications like atelectasis.
D. Discontinue antibiotics on first post-op day
Antibiotics are continued as per provider order, especially with ruptured appendix.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Blood pressure 170/82 mm Hg:
This is a high BP, and verapamil (a calcium channel blocker) can help lower it.
B. Respiratory rate 18/min:
This is a normal RR; no contraindication here.
C. Potassium 4 mEq/L:
This is a normal potassium level.
D. Pulse rate 48/min:
Verapamil lowers heart rate. A pulse <60 bpm (especially <50) is a contraindication due to the risk of bradycardia and heart block.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,B"},"F":{"answers":"A,B"},"G":{"answers":"A,B"}}
Explanation
Lanugo (fine hair) is a classic sign of anorexia due to malnutrition.
Disturbance in body image
Both disorders involve distorted body image, even if the behaviors differ.
Binge eating behavior
Binge eating is characteristic of bulimia, often followed by purging.
Very low weight
Significant underweight is typical in anorexia, while bulimic individuals are often of normal weight.
Peripheral edema
Can occur in both due to malnutrition or purging, especially from electrolyte imbalances or refeeding syndrome.
Self-induced vomiting
Vomiting is a hallmark behavior of bulimia, not typically anorexia unless it's binge-purge type.
Rigorous exercise regimen
Compensatory over-exercising can occur in both disorders as a way to control weight.
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