A patient with suspected appendicitis is being prepared for surgery. Which of the following preoperative interventions should the nurse prioritize?

Apply a heating pad to the abdomen

Administer a cleansing enema

Administer oral analgesics as needed

Place the patient on NPO status

Answer and Explanation

The Correct Answer is D

A. Apply a heating pad to the abdomen: This is incorrect and potentially harmful, as applying heat to the abdomen can increase blood flow and worsen inflammation or risk rupture of the appendix.

B. Administer a cleansing enema: Enemas should not be administered for suspected appendicitis as they may cause irritation and increase the risk of perforation.

C. Administer oral analgesics as needed: Oral analgesics are contraindicated since the patient should be NPO, and strong pain relief might mask the symptoms of a ruptured appendix.

D. Place the patient on NPO status: The highest priority preoperative intervention is to place the patient on NPO (nothing by mouth) status to prevent aspiration during anesthesia, a standard preoperative practice, especially for abdominal surgeries.

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Correct Answer is D

Explanation

A. Provide emotional support: While emotional support is important, addressing physical health issues like fluid and electrolyte balance takes priority during an acute exacerbation.

B. Review stress factors that can cause disease exacerbation: This is important for long-term management but is not the immediate priority during an acute exacerbation.

C. Promote physical mobility: Physical mobility may be limited due to pain or weakness, but it is not the primary concern during an exacerbation.

D. Evaluate fluid and electrolyte levels. Fluid and electrolyte imbalances are common during an exacerbation of ulcerative colitis due to diarrhea and bleeding, making it the top priority to assess and manage to prevent complications such as dehydration or hypovolemia.

A. Measure abdominal girth daily. B. Moisten the client's lips with lemon-glycerin swabs. C. Maintain the client in Fowler's position. D. Use sterile water to irrigate the nasogastric tube.

Correct Answer is A

Explanation

A. Measure abdominal girth daily. Measuring abdominal girth daily helps assess for changes in distention, which is important in monitoring the effectiveness of the decompression.

B. Moisten the client's lips with lemon-glycerin swabs: This is incorrect because lemon-glycerin swabs can dry the oral mucosa. Using plain water or normal saline swabs would be more appropriate.

C. Maintain the client in Fowler's position: This is appropriate as it helps promote drainage from the nasogastric tube and reduces the risk of aspiration.

D. Use sterile water to irrigate the nasogastric tube: Irrigation is typically done with normal saline to maintain electrolyte balance. Sterile water is not recommended for this purpose.

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A patient with suspected appendicitis is being prepared for surgery. Which of the following preoperative interventions should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority?

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