A nurse is planning care for a client who has acute appendicitis.
Which of the following actions should the nurse plan to take?
Administer a laxative to the client.
Keep the client on NPO status.
Place the client's head of bed flat.
Apply heat to the client's abdomen.
The Correct Answer is B
Choice A rationale:
Administering a laxative to a client with acute appendicitis is contraindicated. Laxatives can increase bowel motility, which may aggravate the inflamed appendix and lead to rupture. Rupture of the appendix can result in a life-threatening condition known as peritonitis.
Choice B rationale:
Keeping the client on NPO (nothing by mouth) status is the correct choice. NPO status is essential in the management of acute appendicitis. It helps to rest the bowel, prevents stimulation of the appendix, and decreases the risk of rupture. Oral intake, including food and fluids, is usually restricted until the client undergoes surgery to remove the inflamed appendix (appendectomy).
Choice C rationale:
Placing the client's head of bed flat is not the optimal position for a client with acute appendicitis. Elevating the head of the bed slightly (semi-Fowler's position) can help reduce discomfort and minimize pressure on the abdomen. This position is more comfortable for the client and can aid in pain management.
Choice D rationale:
Applying heat to the client's abdomen is not recommended in acute appendicitis. Heat application can increase blood flow to the area, potentially worsening inflammation and exacerbating pain. Cold packs or ice packs are sometimes used to provide comfort, but their application should be done cautiously to avoid skin damage. However, in many cases, healthcare providers prefer to avoid temperature applications to prevent masking symptoms and signs of worsening appendicitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Upper extremity hypotension is not a common finding in coarctation of the aorta. Coarctation of the aorta typically results in narrowing of the aorta, leading to decreased blood flow to the lower part of the body. This can cause weak or absent femoral pulses and lower extremity hypotension, not upper extremity hypotension.
Choice B rationale:
Frequent nosebleeds are not directly associated with coarctation of the aorta. The symptoms of coarctation of the aorta are primarily related to decreased blood flow to the lower extremities, leading to symptoms such as weak femoral pulses, lower extremity hypotension, and leg cramping or pain.
Choice D rationale:
Increased intracranial pressure is not a typical finding in coarctation of the aorta. Coarctation of the aorta affects blood flow to the lower part of the body and does not directly impact intracranial pressure.
Correct Answer is B
Explanation
The correct answer is Choice B: Assign the child to a negative air pressure room.
Choice A rationale: Assessing the child for Koplik spots is not appropriate in this situation because Koplik spots are associated with measles, not varicella. Koplik spots are small, white, irregular lesions that appear on the buccal mucosa during the prodromal phase of measles. They do not present in cases of varicella, which is characterized by a pruritic, vesicular rash.
Choice B rationale: Assigning the child to a negative air pressure room is the most suitable action because varicella is highly contagious and can be transmitted through airborne particles. A negative air pressure room helps to contain these particles and minimize the risk of infection transmission to other patients, healthcare workers, and visitors. Airborne precautions are the recommended infection control measures for managing varicella cases in healthcare settings.
Choice C rationale: Utilizing droplet precautions alone is insufficient for managing varicella because the virus can also be spread through airborne particles. While droplet precautions may be a component of the overall infection control strategy, they are inadequate without the additional implementation of airborne precautions, such as a negative air pressure room.
Choice D rationale: Administering aspirin to a child with a viral illness is generally contraindicated due to the potential risk of Reye's syndrome, a rare but severe condition characterized by liver failure and encephalopathy. It is essential to follow appropriate guidelines for managing fever and discomfort in pediatric patients with varicella, which typically involve using acetaminophen or ibuprofen instead of aspirin.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.