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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Glargine insulin is a long-acting insulin that provides a basal level of insulin over 24 hours. It is suitable for managing blood glucose levels in clients with diabetes mellitus who require a long-acting insulin to maintain glycemic control throughout the day.

Choice B rationale:

NPH insulin is an intermediate-acting insulin that lasts for about 12-16 hours. While it can be used for blood glucose management, it is not the best choice for a client needing long-acting insulin coverage throughout the day.

Choice C rationale:

Insulin aspart is a rapid-acting insulin used to control postprandial glucose levels. It acts quickly to lower blood sugar after meals and is not suitable for long-acting coverage.

Choice D rationale:

Regular insulin, also known as short-acting insulin, is used to control blood glucose levels during meals. It has a faster onset of action compared to long-acting insulins and is not appropriate for managing basal insulin needs over an entire day.

A. Sitting in high-Fowler's position during the feeding. B. A history of gastroesophageal reflux disease. C. A residual of 65 mL 1 hr postprandial. D. Receiving a high-osmolarity formula.

Correct Answer is B

Explanation

Choice A rationale:

Sitting in high-Fowler's position during the feeding is actually a preventive measure against aspiration. High-Fowler's position, which involves sitting the patient upright at a 90-degree angle, reduces the risk of aspiration by promoting proper digestion and preventing the regurgitation of gastric contents into the lungs.

Choice B rationale:

A history of gastroesophageal reflux disease (GERD) puts the client at risk for aspiration. GERD is a chronic condition in which stomach acid frequently flows back into the esophagus, potentially reaching the throat and lungs, increasing the risk of aspiration during enteral feedings. Aspiration pneumonia, a serious complication, can develop if stomach contents enter the lungs.

Choice C rationale:

A residual of 65 mL 1 hr postprandial indicates that a significant amount of the feeding solution has not been absorbed, raising concerns about delayed gastric emptying. While this situation might require monitoring and adjustments to the feeding regimen, it does not directly increase the risk of aspiration. Aspiration risk is more related to the reflux of stomach contents into the airways.

Choice D rationale:

Receiving a high-osmolarity formula alone does not directly increase the risk of aspiration. High-osmolarity formulas might require careful administration and monitoring to prevent complications, but aspiration risk is more closely associated with the client's underlying conditions, such as GERD.

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A nurse is planning care for a client who has acute appendicitis.Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

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A nurse is planning care for a client who has acute appendicitis.
Which of the following actions should the nurse plan to take?