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 D
Explanation
Choice A reason: This is not an immunization that the nurse should identify as needed for this client because measles, mumps, and rubella are viral diseases that can be prevented by vaccination in childhood or early adulthood. The nurse should ask the client about their vaccination history and check their immunity status by blood tests if necessary.
Choice B reason: This is not an immunization that the nurse should identify as needed for this client because human papilloma virus is a sexually transmitted infection that can cause genital warts or cervical cancer and can be prevented by vaccination before sexual activity or exposure. The nurse should educate the client about safe sex practices and screening tests for cervical cancer.
Choice C reason: This is not an immunization that the nurse should identify as needed for this client because inactivated polio virus is a vaccine that protects against poliomyelitis, a viral disease that can cause paralysis or death and can be prevented by vaccination in childhood or early adulthood. The nurse should ask the client about their vaccination history and check their immunity status by blood tests if necessary.
Choice D reason: This is an immunization that the nurse should identify as needed for this client because herpes zoster is a viral disease that causes shingles, a painful rash with blisters that can affect any part of the body and can be prevented by vaccination in older adults. The nurse should recommend that the client receive two doses of herpes zoster vaccine at least 2 months apart.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because dyspnea, or difficulty breathing, is a sign of fluid overload that can occur during a blood transfusion due to excess volume or rapid infusion rate. The nurse should monitor the client's respiratory rate, oxygen saturation, and lung sounds and slow down or stop the transfusion if dyspnea occurs.
Choice B reason: This is not a sign of fluid overload, but a possible sign of anaphylaxis, which is a severe allergic reaction that can occur during a blood transfusion due to incompatibility or sensitivity to the donor blood. The nurse should monitor the client's pulse, blood pressure, and skin condition and stop the transfusion and administer epinephrine if anaphylaxis occurs.
Choice C reason: This is not a sign of fluid overload, but a possible sign of hemolytic reaction, which is a serious complication that can occur during a blood transfusion due to mismatched blood types or antibodies in the recipient's plasma that destroy the donor's red blood cells. The nurse should monitor the client's temperature, chills, and back pain and stop the transfusion and notify the provider if hemolytic reaction occurs.
Choice D reason: This is not a sign of fluid overload, but a possible sign of mild allergic reaction, which is a common but minor complication that can occur during a blood transfusion due to sensitivity to the donor's plasma proteins. The nurse should monitor the client's skin rash, itching, and hives and administer antihistamines as prescribed if mild allergic reaction occurs.
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