The healthcare provider ordered an IV solution for a dehydrated client with a skull fracture. The nurse knows which IV fluid would be contraindicated?

Choice A reason: Securing the drain to the client's bed sheet is not the best action for the nurse to take. This could cause the drain to be pulled or dislodged if the client moves or changes position. The nurse should secure the drain to the client's gown or abdominal binder, using a safety pin or a clip.

Choice B reason: Removing the JP drain when the drainage has ceased, covering the opening with sterile gauze, is not the correct action for the nurse to take. The nurse should not remove the drain without a physician's order, as this could cause complications such as infection, bleeding, or bile leakage. The nurse should monitor the amount and color of the drainage, and report any changes to the physician.

Choice C reason: Expelling the air from the JP bulb after emptying to re-establish suction is the correct action for the nurse to take. The JP drain works by creating a negative pressure that draws fluid from the surgical site. The nurse should empty the bulb when it is half full, and squeeze it until it collapses before closing the plug. This ensures that the suction is maintained and prevents the fluid from flowing back into the drain.

Choice D reason: Measuring the drainage every hour for the first 8 hr postoperative is not the correct action for the nurse to take. This is too frequent and unnecessary, as the drainage is expected to decrease over time. The nurse should measure the drainage every 8 to 12 hr, or as ordered by the physician, and record the volume and color. The nurse should also report any signs of infection, such as fever, pain, or foul odor.

Choice A reason: This is not a correct manifestation of appendiceal perforation. Blanched abdomen means that the skin of the abdomen is pale or white, which can indicate shock or blood loss. However, it is not a specific sign of appendiceal perforation, as it can occur in other conditions as well.

Choice B reason: This is a correct manifestation of appendiceal perforation. Sudden decrease in abdominal pain means that the pain that was previously felt in the right lower quadrant of the abdomen has subsided or disappeared. This can indicate that the appendix has ruptured and released the pus and bacteria into the peritoneal cavity, causing peritonitis. This is a serious complication that requires immediate surgical intervention.

Choice C reason: This is not a correct manifestation of appendiceal perforation. Absent Rovsing's sign means that there is no pain in the right lower quadrant of the abdomen when the left lower quadrant is palpated. This is a sign of appendicitis, not appendiceal perforation, as it indicates that the appendix is inflamed and irritated by the pressure.

Choice D reason: This is not a correct manifestation of appendiceal perforation. Fever means that the body temperature is above the normal range, which can indicate infection or inflammation. However, it is not a specific sign of appendiceal perforation, as it can occur in other conditions as well.