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.
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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Related Questions
Correct Answer is C
Explanation
Giving a report to a provider in SBAR format is not related to one of the National Patient Safety Goals (NPSGs). The NPSGs are a set of standards developed by The Joint Commission to improve patient safety andquality of care. They address specific areas of concern such as infection prevention, medication safety, patient identification, communication, and alarm management.
Choice A is wrong because refraining from changing alarm settings is related to NPSG 06.01.01, which aims to improve the safety of clinical alarm systems. Choice B is wrong because using 2 patient identifiers for medication administration is related to NPSG 01.01.01, which aims to improve the accuracy of patient identification.
Choice D is wrong because arriving 15 minutes prior to the start of the shift is related to NPSG 02.03.01, which aims to improve the effectiveness of communication among caregivers.
Correct Answer is A
Explanation
This helps increase the oxygen-carrying capacity of the blood and corrects anemia.
Choice B is wrong because erythropoietin is not given to all people with anemia. It is only used for certain types of anemia, such as those caused by chronic kidney disease or chemotherapy.
Choice C is wrong because erythropoietin is not given for iron deficiency anemia. Iron deficiency anemia is treated with iron supplements and dietary changes.
Choice D is wrong because erythropoietin does not stimulate bone marrow production of white blood cells. White blood cells are involved in immune responses and are produced by different growth factors.
Question 22.
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