A nurse is admitting a client who has suspected appendicitis. Which of the following findings is the nurse’s priority to report to the provider?

Distended, board-like abdomen

WBC count 15,000/mm³ (5,000 to 10,000/mm³)

Rebound tenderness over McBurney’s point

Temperature 37.3°C (99.1°F)

Answer and Explanation

The Correct Answer is A

Choice A Reason:

A distended, board-like abdomen is a critical finding that can indicate peritonitis, a severe complication of appendicitis. Peritonitis occurs when the appendix ruptures, leading to infection spreading throughout the abdominal cavity. This condition requires immediate medical intervention to prevent further complications and potential sepsis.

Choice B Reason:

A WBC count of 15,000/mm³ is elevated and suggests an infection, which is common in appendicitis. However, it is not as immediately critical as signs of peritonitis. Elevated WBC counts are expected in cases of appendicitis but do not necessarily indicate a life-threatening emergency.

Choice C Reason:

Rebound tenderness over McBurney’s point is a classic sign of appendicitis and indicates localized inflammation. While it is an important diagnostic sign, it does not require immediate reporting compared to signs of peritonitis.

Choice D Reason:

A temperature of 37.3°C (99.1°F) is only slightly elevated and does not indicate a severe infection or complication. Fever is a common symptom of appendicitis but is not as critical as a distended, board-like abdomen.

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Correct Answer is B

Explanation

Choice A Reason:

Respiratory acidosis is characterized by a low pH (below 7.35) and an elevated PaCO₂ (above 45 mm Hg). This condition occurs when there is an accumulation of carbon dioxide in the blood due to hypoventilation or impaired lung function. In this case, the client’s pH is elevated, and PaCO₂ is low, which does not align with respiratory acidosis.

Choice B Reason:

Respiratory alkalosis is indicated by a high pH (above 7.45) and a low PaCO₂ (below 35 mm Hg). This condition results from hyperventilation, which causes excessive exhalation of carbon dioxide. The client’s ABG results show a pH of 7.50 and a PaCO₂ of 29 mm Hg, consistent with respiratory alkalosis.

Choice C Reason:

Metabolic acidosis is characterized by a low pH (below 7.35) and a low HCO₃ (below 21 mEq/L). This condition occurs due to an accumulation of acids or a loss of bicarbonate in the body. The client’s pH is elevated, and HCO₃ is within the normal range, which does not indicate metabolic acidosis.

Choice D Reason:

Metabolic alkalosis is indicated by a high pH (above 7.45) and a high HCO₃ (above 28 mEq/L). This condition results from an excess of bicarbonate or a loss of acids. The client’s pH is elevated, but HCO₃ is within the normal range, which does not support a diagnosis of metabolic alkalosis.

A. Lidocaine B. Adenosine C. Atropine D. Verapamil

Correct Answer is C

Explanation

Choice A Reason

Lidocaine is primarily used to treat ventricular arrhythmias, such as ventricular tachycardia or ventricular fibrillation. It is not typically used for bradycardia (a heart rate of 40/min) and would not be appropriate for this scenario.

Choice B Reason

Adenosine is used to treat certain types of supraventricular tachycardia (SVT) by slowing down the heart rate. It is not indicated for bradycardia and would not be suitable for a heart rate of 40/min.

Choice C Reason

Atropine is the first-line medication for treating symptomatic bradycardia. It works by blocking the effects of the vagus nerve on the heart, thereby increasing the heart rate. Given the client’s symptoms of a low heart rate, diaphoresis, and chest pain, atropine is the appropriate choice.

Choice D Reason

Verapamil is a calcium channel blocker used to treat high blood pressure, angina, and certain types of arrhythmias. However, it is not used for bradycardia and could potentially worsen the condition by further lowering the heart rate.

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A nurse is admitting a client who has suspected appendicitis. Which of the following findings is the nurse’s priority to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50 (7.35 to 7.45), PaCO₂ 29 mm Hg (35 to 45 mm Hg), and HCO₃ 25 mEq/L (21 to 28 mEq/L). The nurse should identify that the client has which of the following acid-base imbalances?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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