You are reviewing the charts of your patient who is to undergo appendectomy later today. Which among the following chart entries will alert you to call their surgeon?*1 pointA. A nothing-per-orem order since 12:00 MNB. A signed informed consentC. Medications include: phenothiazine, vancomycin, and atropine sulfateD. Medical history of taking multivitamin supplements containing vitamins A, C, D, B complex, and gingko biloba.

Who among the following patients can sign their own informed consent?*1 pointA. A 17-year old prodigy who graduated as summa cum laudeB. A 25-year old man who cannot speakC. A 90-year old woman who is on life saving medicationsD. A 37-year old intoxicated chief of surgery152. You are reviewing the charts of your patient who is to undergo appendectomy later today. Which among the following chart entries will alert you to call their surgeon?*1 pointA. A nothing-per-orem order since 12:00 MNB. A signed informed consentC. Medications include: phenothiazine, vancomycin, and atropine sulfateD. Medical history of taking multivitamin supplements containing vitamins A, C, D, B complex, and gingko biloba.153. Who among the following members of the surgical team is deemed to be following the principles of asepsis?*1 pointA. A circulating nurse who is preparing the mayo tableB. A circulating nurse who is wearing her surgical cap in the wardC. A surgeon who only wears their mask inside the OR theatreD. A scrub nurse who prefers wearing scrubs one size smaller to prevent breaks in asepsis154. 8 hours post-operation, a patient in the PACU suddenly presents with new-onset disorientation, began pulling her IV lines, and screams at the nurse for trapping her in the ward. Medical history reveals that the patient has no history of psychiatric illnesses. What is the appropriate nursing action?*1 pointA. Call the surgeon-in chargeB. Put restraintsC. Administer PRN diazepamD. Reorient the client to person, place, and time155. You are monitoring your patient who is admitted to the PACU 1 hour ago and you noted a 4 x 4 cm, bright red drainage on the dressing of the patient’s operative site. What is your appropriate initial action?*1 pointA. Inspect the wound to get further assessment dataB. Document findings and continue monitoringC. Call the surgeon-in-chargeD. Check the patient’s platelet count156. Your 75-year old post-cholecystectomy patient asks you why you keep on insisting that they walk around the unit. You will answer that the benefits of early ambulation includeI.         Preventing postoperative pneumoniaII.         Preventing postoperative atelectasisIII.         Preventing development of deep vein thrombosisIV.         Preventing development of deliriumV.         Preventing development of postoperative ileusVI.         Preventing development of contractures*1 pointA. I, III, V, VIB. I, II, III, V, VIC. III, IV, V, VID. All of the above157. What intervention written by your staff nurse for a patient who is at risk for developing deep vein thromboembolism will alert you to intervene?*1 pointA. Ensuring activity by asking the patient to dangle the legs before getting out of bed to walkB. Using thigh-high anti-embolism stockingsC. Administering low-dose heparin, as scheduledD. Giving 2500 mL of fluids per day158. A patient who is admitted to the PACU 2 hours ago suddenly presses the call button stating that she vomited. You went to the bedside and confirmed that the patient vomited. What is your initial nursing action?*1 pointA. Elevate the head of bed to semi-Fowler’sB. Assess the patient’s abdomenC. Administer PRN antiemeticsD. Call the surgeon in-charge

MANAGEMENT OF APPENDICITISUncomplicated AppendicitisThe preferred approach to manage patients with uncomplicatedappendicitis is an appendectomy. Several recent randomizedtrials and cohort studies have examined the role of nonopera-tive management of adult patients with appendicitis. 23,24,25 Ineach of these well-designed studies with noninferiority as theendpoint, patients were randomized to either receiving antibiot-ics or undergoing an appendectomy, which was frequently per-formed open. A majority of the patients in the nonoperative armreceived intravenous antibiotics for a short course followed bya course of a fluoroquinolone and metronidazole, or oral amoxi-cillin/clavulanic acid. 23,26,27 Meta-analysis of the published datafound that 26.5% of patients in the nonoperative group requiredan appendectomy within 1 year. In addition, the rate of adverseevents following antibiotics therapy was higher (relative risk[RR] 3.18, 95% CI 1.63–6.21, P = 0.0007), and patients whorecurred presented more frequently with complicated appen-dicitis (RR 2.52, 95% CI 1.17–5.43, P = 0.02). 28,29 Currently,conservative management can be offered to informed patientsusing techniques of shared decision-making, but it is not thestandard modality of management of appendicitis, except inpatients with significant phobia of surgery. 30 Societal costs andlong-term implications of the conservative strategy have not yetbeen completely evaluated.Timing of Surgery. Emergent surgery is often performed inpatients with appendicitis, but studies have evaluated the perfor-mance of urgent surgery (waiting less than 12 hours) in a semi-elective setting after administering antibiotics upon admission.The studies did not reveal any significant difference in outcomes,except for a slightly longer hospital stay in those undergoingurgent surgery.31-33 Currently, delaying surgery less than 12 hoursis acceptable in patients with short duration of symptoms (lessthan 48 hours) and in nonperforated, nongangrenous appendicitis.Approach of Surgery. Numerous meta-analyses comparinglaparoscopic to open appendectomy have demonstrated relativeequivalence of the techniques, with laparoscopic appendec-tomy resulting in a shorter length of stay (LOS), faster return towork, and lower superficial wound infection rates, especiallyin obese patients. 34,35 Open appendectomy results in shorteroperative times and lower intra-abdominal infection rates.36Costs of the two techniques are relatively similar because ofthe offset of costs in laparoscopic techniques by shorter LOS.In the United States, laparoscopic appendectomies are increas-ingly utilized. 37Complicated AppendicitisPerforated and gangrenous appendicitis and appendicitis withabscess or phlegmon formation are considered complicatedconditions. Patients with perforated appendicitis usually pres-ent after 24 hours of onset, although 20% of patients presentwithin 24 hours. Such patients are often acutely ill and dehy-drated and require resuscitation. Usually, the perforated abscessis walled off in the right lower quadrant, although retroperito-neal abscesses including psoas abscess, liver abscesses, fistu-las, and pylephlebitis (portal vein inflammation) can also occurwhen left untreated.Perforated appendicitis can be managed either operativelyor nonoperatively. Immediate surgery is necessary inpatients that appear septic, but this is usually associatedwith higher complications, including abscesses and enterocuta-neous fistulae due to dense adhesions and inflammation.The management of long-duration, complicated appendici-tis is often staged.38,39 Patients are resuscitated and treated withIV antibiotics. 40,41 Patients with longstanding perforation arebetter treated with adequate percutaneous image-guided drain-age.42 This strategy is successful in 79% of patients who achievecomplete resolution, which occurs more often in lower-gradeabscesses, transgluteal drainage, and with CT- (vs. ultrasound-)guided drainage43 Operative intervention is performed in patientswho fail conservative management and in patients with free intra-peritoneal perforation.Interval Appendectomy. The majority of patients with perfo-rated appendicitis (80%) have resolution of their symptoms withdrainage and antibiotics. There remains debate about the valueof performing an interval appendectomy 6 to 8 weeks after theoriginal inflammatory episode. 44-46 Proponents of this approachcite the incidence of recurrent appendicitis (7.4%–8.8%) and thepresence of appendiceal neoplasms detected on the appendec-tomy (relevant benign lesions 0.7%, malignant lesions 1.3%).47Opponents cite the high incidence of no future events after amedian follow-up of 34 months in 91% of patients. Currently,shared decision-making is necessary before proceeding with aninterval appendectom

A week after open appendectomy for perforated appendicitis, the Lanz incision is noted to be erythematous, slightly swollen and tender. The appropriate treatment is:Question 45Select one:a.Incision and drainageb.Systemic antibioticsc.Topical antibiotics’d.Local heat therapye.Regional ultrasound

You receive an order from the physician for a medication, but it's strange the way he wrote it and you aren't sure the dose looks right. You figure he knows what he is doing, so you can give the medication without questioning the physician.ResponsesTrueTrueFalse

Which client statements would indicate an effective understanding of the prescribed cyanocobalamin?"I should increase my fluid intake because this medication may cause constipation.""I may notice black tarry stools with this medication.""I may require additional doses of this medication.""This medication will help my blood coagulate."