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

This type of anemia is caused by the reduced absorption of vitamin B12 in the small intestine after gastric bypass surgery. Vitamin B12 is needed for the production of healthy red blood cells and nerve function. The symptoms of vitamin B12 deficiency anemia include sore tongue, tingling in the fingers, and balance problems.

Choice A is wrong because folic acid deficiency anemia is caused by the lack of folic acid in the diet or increased demand for folic acid, such as during pregnancy.

Folic acid is also needed for red blood cell production, but it does not cause nerve symptoms.

Choice B is wrong because aplastic anemia is caused by the failure of the bone marrow to produce enough blood cells.

It is not related to gastric bypass surgery or nutrient deficiency. It can be caused by infections, drugs, radiation, or autoimmune diseases.

Choice D is wrong because acquired anemia is a general term for any type of anemia that is not inherited or present at birth.

It can have many causes, such as blood loss, infection, inflammation, or chronic disease.

It does not specify the type of anemia or the underlying mechanism. Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women. Normal ranges for vitamin B12 are 200 to 900 pg/mL.

A. Protecting the client’s bones with strict bedrest. B. Providing the client with assisted range of motion exercises twice daily. C. Decreasing the amount of calcium in the client’s diet. D. Increasing regular weight-bearing activities.

Correct Answer is D

Explanation

Increasing regular weight-bearing activities can help prevent osteoporosis by stimulating bone formation and improving muscle strength. Weight-bearing activities are those that make your bones and muscles work against gravity, such as walking, jogging, dancing, or lifting weights.

Choice A is wrong because protecting the client’s bones with strict bedrest can actually increase the risk of osteoporosis by reducing bone density and muscle mass. Bedrest should be avoided unless medically necessary.

Choice B is wrong because providing the client with assisted range of motion exercises twice daily is not enough to prevent osteoporosis. While these exercises can help maintain joint mobility and flexibility, they are not weight bearing and do not stimulate bone formation.

Choice C is wrong because decreasing the amount of calcium in the client’s diet can also increase the risk of osteoporosis. Calcium is an essential mineral for bone health and adults need 700mg a day, which can be obtained from foods such as dairy products, leafy green vegetables, tofu, and dried fruit. Vitamin D is also important for bone health as it helps the body absorb calcium.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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?

Correct Answer is D

Explanation

A nurse is assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?

An elderly client is hospitalized for the first time. Which of the following actions ensures the safety of the client? (Select all that apply).

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse’s priority?

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

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?

The RN identifies that a client is at risk for impaired skin integrity. Which interventions should the nurse add to this client’s plan of care?

The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

A nurse is caring for a client with chronic fatigue syndrome. Which of the following criteria were used to assist in making this diagnosis? Select all that apply.