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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Cataracts are a cloudy, opaque area over the lens of one eye that can impair vision
Choice B is wrong because diabetic retinopathy is a condition that affects the blood vessels of the retina, not the lens. It can cause blurred vision, floaters, or vision loss
Choice C is wrong because glaucoma is a condition that damages the optic nerve due to high pressure in the eye. It can cause blind spots, halos around lights, or vision loss
Choice D is wrong because macular degeneration is a condition that damages the macula, the central part of the retina. It can cause blurred or no vision in the center of the visual field
: https://www.nhs.uk/conditions/cataracts/
: https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and diseases/diabetic-retinopathy
: https://www.mayoclinic.org/diseases-conditions/glaucoma/symptoms causes/syc-20372839
: https://en.wikipedia.org/wiki/Macular_degeneration
Correct Answer is D
Explanation
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
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