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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because the nurse had a legal obligation to turn the client every two hours as ordered, and by failing to do so, they did not exercise reasonable care that could foreseeably prevent harm to the client. This is an example of negligence, which requires four elements: duty, breach, injury and causation.
Choice B is wrong because criminality refers to the violation of criminal laws, such as theft or assault, which are not applicable in this case.
Choice C is wrong because scope of practice refers to the range of activities that a health care professional is authorized to perform based on their education, training and certification.
The nurse’s failure to turn the client does not relate to their scope of practice. Choice D is wrong because false imprisonment refers to the unlawful restraint of a person’s freedom of movement, such as locking them in a room or restraining them against their will.
The nurse’s failure to turn the client does not involve any such restraint.
Correct Answer is C
Explanation
According to Mayo Clinic, physical therapy and exercises can improve strength, flexibility and stamina for people with fibromyalgia.
Low-impact aerobics, such as swimming or biking, are recommended as they are less likely to cause muscle soreness or injury.
Choice A is wrong because antidepressant medications can help ease the pain and fatigue associated with fibromyalgia.
They are often prescribed as part of the treatment plan.
Choice B is wrong because physical manifestations of the disease do not become progressively worse despite treatment.
Fibromyalgia is a chronic condition, but it does not damage the joints, muscles or organs.
Choice D is wrong because narcotic analgesia will not be used for long-term pain control. Opioid medications can cause significant side effects and dependence and will worsen the pain over time.
They are not recommended for fibromyalgia treatment.
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