Practice Quiz

CMSRN Medical-Surgical Nursing

Category - Gastrointestinal

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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 that the abdomen is distended and bowel sounds are diminished. Which is the appropriate nursing intervention?
  1. Notify the physician
  2. Administer the prescribed pain medication
  3. Call and ask the operating room team to perform the surgery as soon as possible
  4. Reposition the client and apply a heating pad on warm setting to the client’s abdomen
Explanation
Answer - A - Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.
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