A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect?(Select all that apply.).

Elevated WBC Count.

Elevated amylase level.

Rebound tenderness.

Ascites.

Anorexia.

Answer and Explanation

Correct Answer : A,C,E

Choice A rationale:

An elevated white blood cell (WBC) count is an expected manifestation in a client with suspected appendicitis. Inflammation in the appendix leads to an immune response, causing an increase in WBC count.

Choice B rationale:

Elevated amylase level is not typically associated with appendicitis. Elevated amylase is more commonly seen in pancreatitis, not appendicitis.

Choice C rationale:

Rebound tenderness, which refers to increased pain when pressure is released rather than applied, is a classic symptom of appendicitis. The nurse should expect to find rebound tenderness during the abdominal assessment.

Choice D rationale:

Ascites are not a common manifestation of appendicitis. Ascites is the accumulation of fluid in the abdominal cavity and are more commonly seen in liver cirrhosis and certain other conditions, but not in appendicitis.

Choice E rationale:

Anorexia, or loss of appetite, can be seen in clients with appendicitis due to the inflammation and discomfort in the abdominal region.

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Correct Answer is B

Explanation

Choice A rationale:

Hemoptysis, which is the coughing up of blood, is not typically associated with a urinary tract infection (UTI). It is more commonly related to respiratory or pulmonary issues.

Choice B rationale:

Hematuria, the presence of blood in the urine, is a common finding in a UTI. Inflammation and infection in the urinary tract can lead to the presence of blood cells in the urine.

Choice C rationale:

Hyperglycemia, an elevated blood glucose level, is not directly related to a UTI. It may be seen in individuals with diabetes, but it is not a typical finding in a UTI.

Choice D rationale:

Hypocalcemia, a low level of calcium in the blood, is not a characteristic finding in a UTI. UTIs primarily affect the urinary system and do not directly involve calcium metabolism.

A. Close the pinch clamp on the CVC. B. Obtain a prescription for stat ABGS (Arterial Blood Gas Studies). C. Place the client in the left Trendelenburg position. D. Check the tubing for placement of a locking adaptor.

Correct Answer is A

Explanation

Choice A rationale:

The nurse's first priority in this situation should be to close the pinch clamp on the central venous catheter (CVC). This will prevent air from entering the client's vascular system and causing an air embolism, which can lead to serious complications. Once the clamp is closed, the nurse can then proceed with further assessments and interventions.

Choice B rationale:

Obtaining a prescription for stat ABGS (Arterial Blood Gas Studies) is not the first action the nurse should take in this situation. While ABGS may be relevant later to assess the client's respiratory status, the immediate concern is to prevent air embolism by closing the disconnected IV tubing.

Choice C rationale:

Placing the client in the left Trendelenburg position is not the first priority in this situation. The Trendelenburg position is used to increase venous return and is typically indicated in cases of hypotension or shock. Closing the clamp to prevent an air embolism should be the nurse's initial action.

Choice D rationale:

Checking the tubing for the placement of a locking adaptor is not the first action the nurse should take. While it is essential to ensure that the IV tubing is properly connected and secured, preventing the air from entering the CVC should take precedence in this urgent situation.

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A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect?(Select all that apply.).

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Explanation

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