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 C

Explanation

A patient with a BMI of 38 is considered to have obesity, which means they have excess body fat that may impair their mobility and increase their risk of complications such as pressure ulcers, infections, and respiratory problems. A bariatric bed is designed to accommodate the weight and size of obese patients, and a trapeze bar can help them change positions and transfer to a chair or wheelchair.

These interventions can promote comfort, safety, and independence for the patient.

Choice A is wrong because hourly vital signs are not necessary for a patient with obesity unless they have other conditions that warrant frequent monitoring.

Choice B is wrong because implementing all fall risk precautions may be excessive and restrictive for a patient with obesity who is otherwise stable and alert.

Choice D is wrong because supine positioning can compromise the patient’s breathing and circulation, and increase the risk of pressure ulcers and aspiration.

The patient should be encouraged to change positions frequently and elevate the head of the bed when lying down.

A. The teenager is probably difficult for a single mother to manage, so the family will be referred to social services. B. Further assessment needs to be done to determine if the family needs assistance. C. The mother needs assistance to cope with the stress of raising a teenager on her own. D. The mother will need financial support while she takes off work to care for her son.

Correct Answer is B

Explanation

This is because the nurse should not make assumptions about the family’s functionality based on their history or situation, but rather gather more information to identify their strengths and needs.

Choice A is wrong because it implies that the teenager is a problem and the mother is incapable of managing him, which is disrespectful and judgmental.

Choice C is wrong because it assumes that the mother is stressed and needs coping skills, which may not be true.

Choice D is wrong because it suggests that the mother is financially dependent on her son, which is not relevant to the question.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with a BMI of. Appropriate nursing interventions include:

Correct Answer is C

Explanation

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?

Correct Answer is B

Explanation

The nurse knows that infants have a high risk of hypothermia due to decreased brown fat, immature skin, and poorly developed thermoregulatory mechanism. Which nursing intervention is done to prevent heat loss by conduction?

The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus (gas). Given this information, which action is most appropriate by the nurse?

A person with anemia is prescribed erythropoietin subcutaneously. The nurse knows that erythropoietin:

The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?

An elderly man fell during his hospitalization and has died from a head injury sustained in the fall. What is the role of the risk manager in this situation?

A client sees his primary care physician for complaints of fatigue. Bloodwork shows the client is anemic. Upon physical assessment, what signs would the provider expect to see? (Select all that apply)

A nurse is teaching about values to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding?

A nurse is discussing the reporting of elder abuse with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?