The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes the abdomen is distended and bowel sounds are diminished.
Which is the most appropriate nursing intervention?

Administer the prescribed medication.

Reposition the client and apply a heating pad on the warm setting to the client’s abdomen.

Call the healthcare provider.

Call and ask the operating room team to perform surgery as soon as possible.

Answer and Explanation

The Correct Answer is C

The client may have a ruptured appendix, which is a life-threatening complication of appendicitis. A ruptured appendix can cause peritonitis, which is an infection of the lining of the abdomen, or an abscess, which is a collection of pus around the appendix. These conditions require immediate medical attention and surgery to remove the appendix and clean the abdominal cavity.

Choice A is wrong because administering the prescribed medication may mask the symptoms of a ruptured appendix and delay diagnosis and treatment.

Choice B is wrong because repositioning the client and applying a heating pad may increase the risk of rupture or spread of infection.

Choice D is wrong because calling the operating room team is not the nurse’s responsibility and may not be feasible depending on the availability of the surgical team and the operating room.

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Correct Answer is A

Explanation

Watching television until falling asleep at night is a poor sleep habit because it can interfere with the body’s natural sleep-wake cycle and make it harder to fall asleep and stay asleep. Television can also expose the eyes to bright light and stimulating or stressful content, which can affect the production of melatonin, a hormone that regulates sleep.

Choice B is wrong because having a small snack and taking a bath before going to bed each day are good sleep habits that can promote relaxation and sleep quality.

Choice C is wrong because not taking naps throughout the day is a good sleep habit that can help maintain a consistent sleep schedule and avoid disrupting the night-time sleep.

Choice D is wrong because going to bed and getting up at the same times each day is a good sleep habit that can reinforce the body’s circadian rhythm and make it easier to fall asleep and wake up.

A. a huge barrier in accessing health care. B. due to politics; not something nurses get involved with. C. only a problem for those who do not speak English. D. regulated by the Joint Commission.

Correct Answer is A

Explanation

A lack of insurance or lack of sufficient insurance is a huge barrier in accessing health care. According to the Kaiser Family Foundation, uninsured people are less likely to receive preventive care and services for major health conditions and chronic diseases. They also face greater difficulties in affording care and paying medical bills.

Choice B is wrong because politics is not the only factor that affects the availability and affordability of health insurance. Other factors include income, employment status, age, health status, and geographic location. Nurses have a professional and ethical responsibility to advocate for the health needs of their clients and communities, which may involve engaging with political issues. Choice C is wrong because language is not the only problem for uninsured or underinsured clients. Other problems include cost, access, quality, and continuity of care. Language barriers may affect communication and understanding between clients and providers, but they can be addressed by using interpreters, translators, or culturally competent staff.

Choice D is wrong because the Joint Commission does not regulate insurance coverage. The Joint Commission is an independent, nonprofit organization that accredits and certifies health care organizations and programs in the United States. It sets standards for quality and safety of care, but it does not determine who is eligible for insurance or what benefits are covered.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further instructions?

Correct Answer is A

Explanation

The nurse educator is presenting information to a group of nursing students regarding uninsured and underinsured clients. The nurse educator emphasizes that a lack of insurance or lack of sufficient insurance is:

Correct Answer is A

Explanation

While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

Your patient was outdoors and developed hypothermia. You know that independent nursing interventions would include:

The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

A client is admitted with an exacerbation of COPD. He has a long history of chronic bronchitis. What physical finding does the nurse expect in a client with chronic bronchitis?

The nurse knows that the first-line treatment for localized inflammation (for example, on a patient’s ankle) is RICE. This acronym means:

The RN learns that the father of a teenage client was killed in a car accident when he was a baby, and his mother has raised him on her own. How should the nurse interpret this family’s functionality?

An elderly client is hospitalized for the first time. Which of the following actions ensures the safety of the client? (Select all that apply).