HESI RN Med Surg
HESI RN Med Surg ( 40 Questions)
A 9-year-old admitted to the unit with severe abdominal pain and fever is diagnosed with appendicitis and is placed on the surgery schedule for an appendectomy. The child reports to the nurse of experiencing sudden relief in abdominal pain. Which action should the nurse take first?
Giving prescribed intravenous antibiotics is not the first action that the nurse should take. Antibiotics are used to treat the infection and inflammation caused by appendicitis, but they are not enough to prevent the complications of a ruptured appendix. The nurse should administer the antibiotics as ordered, but only after notifying the healthcare provider of the change in the child's condition.
Inquiring about the client's last meal is not the first action that the nurse should take. The last meal may be relevant for the preparation of the surgery, but it is not urgent or related to the sudden relief of pain. The nurse should ask about the last meal as part of the preoperative assessment, but only after contacting the healthcare provider.
Contacting the healthcare provider is the first action that the nurse should take. Sudden relief of pain in a child with appendicitis may indicate a perforation or rupture of the appendix, which is a life-threatening emergency. The nurse should immediately report this finding to the healthcare provider, who may order additional tests or expedite the surgery.
Documenting the client's relief of pain is not the first action that the nurse should take. Documentation is an important part of nursing care, but it is not a priority in this situation. The nurse should document the child's pain level, vital signs, and interventions, but only after contacting the healthcare provider and taking appropriate actions.
Choice A reason: Giving prescribed intravenous antibiotics is not the first action that the nurse should take. Antibiotics are used to treat the infection and inflammation caused by appendicitis, but they are not enough to prevent the complications of a ruptured appendix. The nurse should administer the antibiotics as ordered, but only after notifying the healthcare provider of the change in the child's condition.
Choice B reason: Inquiring about the client's last meal is not the first action that the nurse should take. The last meal may be relevant for the preparation of the surgery, but it is not urgent or related to the sudden relief of pain. The nurse should ask about the last meal as part of the preoperative assessment, but only after contacting the healthcare provider.
Choice C reason: Contacting the healthcare provider is the first action that the nurse should take. Sudden relief of pain in a child with appendicitis may indicate a perforation or rupture of the appendix, which is a life-threatening emergency. The nurse should immediately report this finding to the healthcare provider, who may order additional tests or expedite the surgery.
Choice D reason: Documenting the client's relief of pain is not the first action that the nurse should take. Documentation is an important part of nursing care, but it is not a priority in this situation. The nurse should document the child's pain level, vital signs, and interventions, but only after contacting the healthcare provider and taking appropriate actions.