A nurse is preparing a client who has acute appendicitis for surgery. Which of the following actions should the nurse take?
Apply a heat pack to the client's lower abdomen.
Place the client in semi-Fowler's position.
Give the client a clear liquid diet.
Administer an enema to the client.
The Correct Answer is B
A. Apply a heat pack to the client's lower abdomen: This is incorrect as applying heat can worsen inflammation and increase the risk of rupture; ice packs are generally used instead.
B. Place the client in semi-Fowler's position: This is correct as the semi-Fowler's position helps reduce pain and pressure on the abdomen and can improve comfort before surgery.
C. Give the client a clear liquid diet: This is incorrect as a clear liquid diet is not appropriate for a client with acute appendicitis who may require NPO (nothing by mouth) status prior to surgery.
D. Administer an enema to the client: This is incorrect as enemas are contraindicated in acute appendicitis due to the risk of perforation and worsening of the condition.
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Related Questions
Correct Answer is D
Explanation
A. Have the client drink contrast medium: This is incorrect as contrast medium is typically not required for an esophagogastroduodenoscopy (EGD); it is used for other types of imaging studies.
B. Shave the client from axillae to groin: This is incorrect; shaving is not necessary for an EGD procedure.
C. Administer a cleansing enema: This is incorrect as an enema is generally not required for an EGD, which focuses on the upper gastrointestinal tract.
D. Ensure the signed consent is in the medical record: This is correct as ensuring that the consent form is signed and documented is crucial for legal and procedural reasons before performing an EGD.
Correct Answer is C
Explanation
A. "Knee-high stockings can be rolled down slightly to provide comfort": Rolling down antiembolic stockings can cause bunching and reduce their effectiveness in preventing deep vein thrombosis. They should fit smoothly without rolling.
B. "I should flex my toes when applying the stockings": To apply the stockings, the toes should be pointed or relaxed, not flexed, to ensure proper application and avoid discomfort.
C. "The thigh-high stockings should reach just above the gluteal folds": This is correct as thigh-high stockings should extend to just above the gluteal folds to ensure proper fit and effectiveness in preventing blood clots.
D. "I should reapply the stockings before I get out of bed": Antiembolic stockings are typically applied in the morning after getting out of bed and should remain on throughout the day. Reapplying before getting out of bed is not necessary.
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