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 D

Explanation

A client with chronic bronchitis is expected to have a cough that produces sputum for at least 3 months during two successive years. This is due to the hyperplasia of mucous glands and bronchial wall inflammation that occur in chronic bronchitis.

Choice A is wrong because SpO2 >92% is not a specific finding for chronic bronchitis.

SpO2 is a measure of oxygen saturation in the blood and can vary depending on many factors, such as altitude, smoking, and lung diseases. SpO2 may be lower than normal in COPD patients due to airflow obstruction and impaired gas exchange.

Choice B is wrong because underweight is not a typical finding for chronic bronchitis.

Underweight may be more associated with emphysema, which is another component of COPD that involves the destruction of alveolar walls and enlargement of air spaces. Emphysema can cause weight loss due to increased work of breathing and decreased appetite.

Choice C is wrong because bradypnea is not a common finding for chronic bronchitis.

Bradypnea is abnormally slow breathing rate and can be caused by various conditions, such as brain injury, drug overdose, or sleep apnea. Chronic bronchitis usually causes tachypnea, which is abnormally fast breathing rate, due to hypoxia and hypercapnia.

A. A client who has a family history of breast cancer is scheduled for a mammogram. B. A client who has heart failure is scheduled for an echocardiogram. C. A client who is asymptomatic is not scheduled for a series of tests. D. A client is scheduled to receive an influenza vaccination.

Correct Answer is A

Explanation

This is an example of secondary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complications. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.

A client who has a family history of breast cancer and is scheduled for a mammogram is an example of secondary prevention. Secondary prevention is early detection of a disease before it progresses. Secondary prevention can include screenings and other forms of diagnostic tests.

This is an example of tertiary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complication. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.

Choice C is wrong because it is not an example of any level of prevention.

A client who is asymptomatic is not scheduled for a series of tests because there is no indication of any disease or risk factor.

Choice D is wrong because it is an example of primary prevention, which is the action taken to prevent the development of disease.

A client who is scheduled to receive an influenza vaccination is protected from getting infected by the virus and developing flu-related complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention. The nurse should include which of the following as an example of secondary prevention?

Correct Answer is A

Explanation

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

Which thermoregulatory condition is an elderly person most at risk for?

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

A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues?

A client who is at risk for developing osteoporosis asks what can be done to decrease the risk of actually developing the disorder. Which intervention would be the most beneficial for this client?

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

A new nurse is working in a hospital. Which of the following actions by the nurse is NOT related to one of the National Patient Safety Goals?

Which of the following nursing diagnoses would typically NOT be associated with anemia?