A nurse is collecting data from a client who has been admitted with suspected appendicitis. Which of the following findings is the nurse's priority to report to the provider?
Temperature 37.8° C (100° F)
Loss of appetite
WBC count 15,000/mm³
Rigid, board-like abdomen
The Correct Answer is D
Choice A reason: This is not a priority finding to report to the provider because temperature 37.8° C (100° F) indicates a mild fever that can be caused by inflammation or infection of the appendix or other organs. The nurse should monitor the client's temperature and administer antipyretics as prescribed.
Choice B reason: This is not a priority finding to report to the provider because loss of appetite is a common symptom of appendicitis that can result from nausea, vomiting, or pain. The nurse should encourage oral fluid intake and provide clear liquids or bland foods as tolerated.
Choice C reason: This is not a priority finding to report to the provider because WBC count 15,000/mm³ indicates leukocytosis or elevated white blood cell count that can be caused by inflammation or infection of the appendix or other organs. The nurse should monitor the client's laboratory values and administer antibiotics as prescribed.
Choice D reason: This is a priority finding to report to the provider because rigid, board-like abdomen indicates peritonitis or inflammation of the peritoneum that can be caused by rupture or perforation of the appendix or other organs. This is a medical emergency that requires immediate surgical intervention and aggressive fluid and antibiotic therapy. The nurse should assess the client's abdominal pain, distension, and guarding and notify the provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is an indication that the client needs further testing because a palpable area of induration, greater than 10 mm (0.4 in) in diameter, is considered a positive result for the tuberculin skin test, which means that the client has been exposed to Mycobacterium tuberculosis and may have latent or active tuberculosis infection. The nurse should refer the client for chest x-ray and sputum culture and sensitivity tests to confirm the diagnosis and rule out other conditions.
Choice B reason: This is not an indication that the client needs further testing because an area of ecchymosis, greater than 12 mm (0.5 in) in diameter, is not considered a positive result for the tuberculin skin test, which means that the client has not been exposed to Mycobacterium tuberculosis and does not have latent or active tuberculosis infection. The nurse should document the finding and monitor the site for any signs of infection or inflammation.
Choice C reason: This is not an indication that the client needs further testing because tenderness at the injection site is not considered a positive result for the tuberculin skin test, which means that the client has not been exposed to Mycobacterium tuberculosis and does not have latent or active tuberculosis infection. The nurse should document the finding and provide comfort measures as needed.
Choice D reason: This is not an indication that the client needs further testing because a nonpalpable area of redness, less than 5 mm (0.2 in) in diameter, is considered a negative result for the tuberculin skin test, which means that the client has not been exposed to Mycobacterium tuberculosis and does not have latent or active tuberculosis infection. The nurse should document the finding and educate the client about tuberculosis prevention and screening recommendations.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because maintaining direct pressure over the site can help stop the bleeding by compressing the blood vessels and promoting clot formation. The nurse should apply firm and continuous pressure for at least 15 minutes or until the bleeding stops.
Choice B reason: This is not an appropriate action because reinforcing the dressing over the site can obscure the assessment of the bleeding and increase the risk of infection. The nurse should change the dressing only when it becomes saturated or as prescribed.
Choice C reason: This is not an appropriate action because obtaining a radial pulse is not relevant to the management of bleeding from a small laceration on the arm. The nurse should monitor the client's vital signs, especially blood pressure and heart rate, to detect signs of shock or blood loss.
Choice D reason: This is not an appropriate action because checking whether the bleeding has stopped can disrupt the clotting process and cause more bleeding. The nurse should avoid lifting or removing the dressing until the bleeding stops or as prescribed.
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