The nurse is caring for a client who has suspected appendicitis. While waiting for surgery, nursing interventions for this client would include: (NOTE: Assume that there are physician's orders for all interventions which would require them.) (SELECT ALL THAT APPLY)
giving the client a heating pad to place on the abdomen for comfort.
getting the client up to walk at least once every hour.
administering a cleansing enema in preparation for surgery.
administering prophylactic IV antibiotics.
keeping the client NPO.
Correct Answer : D,E
D. Prophylactic antibiotics are often administered before surgery for appendicitis to reduce the risk of postoperative infection, particularly in cases of suspected or confirmed appendiceal perforation.
E. Keeping the client NPO (nothing by mouth) is a standard precaution before surgery to prevent aspiration of gastric contents during anesthesia induction and to reduce the risk of surgical complications.
A. Applying heat to the abdomen can potentially worsen inflammation and increase the risk of appendiceal rupture.
B. Ambulation may exacerbate the pain and increase the risk of complications, such as appendiceal rupture.
C. Administering a cleansing enema in preparation for surgery may be appropriate in some cases to help prepare the bowel for surgery, particularly if there is concern about bowel obstruction or to reduce the risk of contamination during surgery.
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Related Questions
Correct Answer is B
Explanation
B. It is essential to complete the full course of antibiotics as prescribed by the healthcare provider, even if symptoms improve before the course is finished. This ensures that all bacteria causing the infection are eradicated, reducing the risk of recurrence and development of antibiotic resistance.
A. Antibiotics should be taken exactly as prescribed and for the full duration of the treatment course. Incomplete or inconsistent use of antibiotics can lead to incomplete eradication of the infection, development of antibiotic resistance, and recurrence of the infection.
C. While cranberry juice is often recommended for urinary tract health due to its ability to prevent bacterial adherence to the bladder wall, it is not a substitute for antibiotics in treating urinary tract infections.
D. Typically, urine cultures are reserved for cases where the diagnosis is uncertain, or the infection is recurrent or complicated. In uncomplicated UTIs, empirical antibiotic treatment based on symptoms and clinical presentation is usually sufficient.
Correct Answer is A
Explanation
A. Sit the client up and provide supplemental oxygen is the correct priority intervention. Chest pain and shortness of breath can be indicative of pulmonary embolism or other respiratory complications, which require immediate attention. Sitting the client up helps improve respiratory mechanics, and providing supplemental oxygen can support oxygenation while further assessments are conducted.
B. While contacting the physician and obtaining an arterial blood gas may be necessary to assess respiratory status and oxygenation, it is not the immediate priority. The client's symptoms require immediate intervention to ensure adequate oxygenation and prevent further deterioration.
C. Chest pain and shortness of breath are not typically expected findings after bariatric surgery and could indicate serious complications. It is essential not to dismiss the client's symptoms but to take them seriously and initiate appropriate interventions.
D. While the use of an incentive spirometer is important for preventing respiratory complications after surgery, it is not the priority intervention in this situation. The client's current symptoms require immediate attention to address potential respiratory distress or other serious complications.
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