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The nurse is caring for a client with suspected appendicitis. Nursing interventions for this client would include: (SELECT ALL THAT APPLY)

Withholding food and fluids until a diagnosis is established.

Administering prophylactic IV antibiotics.

Giving the client a heating pad to place on the abdomen for comfort.

Administering a cleansing enema in preparation for surgery.

Having the client ambulate at least once every hour.

Answer and Explanation

Correct Answer : A,B

Choice A rationale

Withholding food and fluids is essential to prevent complications should surgery be needed.

Choice B rationale

Administering prophylactic IV antibiotics helps prevent infection, which is critical in cases of appendicitis.

Choice C rationale

Applying heat to the abdomen can increase circulation and the risk of rupture in appendicitis.

Choice D rationale

Administering an enema can increase the risk of perforation in appendicitis.

Choice E rationale

Ambulation can exacerbate pain and the risk of rupture in a client with suspected appendicitis.

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Correct Answer is C

Explanation

Choice A rationale

Normal flora does not function as cell rebuilders. They primarily exist in a symbiotic relationship with the host without directly participating in cell repair processes.

Choice B rationale

While some normal flora aid in digestion, they are not involved in blood production. Blood production is a function of bone marrow and not influenced by normal flora.

Choice C rationale

Normal flora play a crucial role in preventing the colonization of pathogens by competing for nutrients and space, thereby protecting the body from harmful microorganisms.

Choice D rationale

Normal flora do not manage the fluid balance of the body. Fluid balance is regulated by the kidneys and the body's endocrine system, not by the normal flora.

A. 7 minutes. B. 6 minutes. C. 5 minutes. D. 3 minutes.

Correct Answer is C

Explanation

Choice A rationale

While a scrub time of 7 minutes can be effective, it exceeds the necessary average time and may cause skin irritation with prolonged scrubbing.

Choice B rationale

A 6-minute scrub is also effective but similarly exceeds the average time, which is typically shorter to balance effectiveness and skin health.

Choice C rationale

A 5-minute scrub is the standard average time, balancing thoroughness in removing transient microorganisms with skin integrity.

Choice D rationale

A 3-minute scrub is often considered too short to ensure adequate removal of microorganisms, potentially compromising aseptic technique.

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The nurse is caring for a client with suspected appendicitis. Nursing interventions for this client would include: (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse explains that the body's normal flora serves as:

Correct Answer is C

Explanation

The nurse performing a surgical scrub is aware that the average time for the scrub is:

Correct Answer is C

Explanation

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When the nurse performs a procedure using sterile technique in the patient's unit, it means that:

The nurse is caring for a client with suspected appendicitis. Nursing interventions for this client would include: (SELECT ALL THAT APPLY)

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