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 C
Explanation
Choice A reason: This is not a statement that indicates acceptance, but rather denial or grief. The client is expressing a desire to return to their previous state and ignoring the reality of their situation. The nurse should acknowledge the client's feelings and provide emotional support and education.
Choice B reason: This is not a statement that indicates acceptance, but rather unrealistic or magical thinking. The client is expecting an impossible outcome and avoiding the facts of their condition. The nurse should explain the function and care of the ileostomy and clarify any misconceptions.
Choice C reason: This is a statement that indicates acceptance, as well as coping and resilience. The client is demonstrating a willingness to adapt to their new situation and seek help from others who have similar experiences. The nurse should praise the client's positive attitude and provide information and resources about support groups.
Choice D reason: This is not a statement that indicates acceptance, but rather avoidance or dependency. The client is showing a lack of interest or involvement in their self-care and relying on their partner to perform the tasks for them. The nurse should encourage the client's participation and independence and teach them how to empty and change the bag.
Correct Answer is B
Explanation
Choice A reason: This is not an appropriate action because performing hand hygiene with hands at elbow level can contaminate or recontaminate hands by allowing water or soap to drip from elbows to hands or wrists. The nurse should perform hand hygiene with hands lower than elbows and avoid touching faucets or sinks with hands or forearms.
Choice B reason: This is an appropriate action because cleaning a blood spill with chlorine bleach can disinfect and decontaminate surfaces that have been exposed to bloodborne pathogens, such as hepatitis B virus or human immunodeficiency virus. The nurse should wear gloves and use a 1:10 dilution of bleach and water to clean the spill.
Choice C reason: This is not an appropriate action because instructing a female client to wipe her perineal area from back to front can increase the risk of urinary tract infection or vaginal infection by introducing bacteria from the anus to the urethra or vagina. The nurse should instruct the client to wipe her perineal area from front to back and use a clean tissue for each wipe.
Choice D reason: This is not an appropriate action because rolling soiled linen with clean side in before placing it in laundry bag can spread microorganisms or body fluids to hands, clothing, or environment. The nurse should fold or roll soiled linen with dirty side in and avoid shaking or tossing it.
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