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 the correct answer because auscultating the client's abdomen for bowel sounds is an assessment that can provide information about the client's bowel motility and function. The nurse should listen for at least 5 minutes in each quadrant and note the frequency, intensity, and quality of bowel sounds.
Choice B reason: This is not an appropriate action to take first because providing privacy with a set time to defecate is an intervention that can promote regular bowel elimination and prevent constipation. The nurse should perform this action after assessing the client's bowel sounds and other factors that may affect defecation, such as pain, medication, diet, and activity.
Choice C reason: This is not an appropriate action to take first because encouraging oral intake of fluids is an intervention that can soften stool and facilitate bowel movement. The nurse should perform this action after assessing the client's bowel sounds and fluid balance status.
Choice D reason: This is not an appropriate action to take first because administering a fiber-based laxative is an intervention that can increase bulk and stimulate peristalsis. The nurse should perform this action after assessing the client's bowel sounds and contraindications for laxatives, such as bowel obstruction, impaction, or perforation.
Correct Answer is B
Explanation
Choice A reason: Taking four nitroglycerin sublingual tablets if having chest pain is an incorrect statement that indicates a lack of understanding of the teaching. Nitroglycerin is a medication that dilates the coronary arteries and relieves angina by improving blood flow to the heart. The client should take one nitroglycerin tablet every 5 minutes for up to three doses if having chest pain. If the pain persists after three doses, the client should call emergency response.
Choice B reason: Notifying emergency response if having sudden jaw pain is a correct statement that indicates an understanding of the teaching. Jaw pain is one of the possible signs of a heart attack, which is a life-threatening condition that occurs when the blood supply to the heart is blocked. Other signs of a heart attack include chest pain, arm pain, shortness of breath, nausea, sweating, or dizziness. The client should seek immediate medical attention if experiencing any of these symptoms.
Choice C reason: Waiting 30 minutes before taking action if having heartburn is an incorrect statement that indicates a lack of understanding of the teaching. Heartburn is a burning sensation in the chest or throat that can be caused by acid reflux, gastritis, or other gastrointestinal disorders. However, heartburn can also mimic or mask angina or a heart attack, especially in women, elderly, or diabetic clients. The client should not ignore or delay seeking help if having chest discomfort that may be related to cardiac problems.
Choice D reason: Having hot, dry, and flushed skin if having a heart attack is an incorrect statement that indicates a lack of understanding of the teaching. Hot, dry, and flushed skin is not a typical sign of a heart attack, but it may indicate fever, dehydration, or allergic reaction. The client should monitor his temperature and hydration status and report any abnormal findings to the provider.
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