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 of a wound infection because redness around the incision line or erythema is a sign of inflammation that can result from bacterial invasion and proliferation in the wound site. The nurse should inspect the wound site for other signs of infection, such as warmth, swelling, pain, or purulent drainage, and collect wound cultures and administer antibiotics as prescribed.
Choice B reason: This is not an indication of a wound infection because serous wound drainage or clear, watery fluid is a normal finding in the first 3 days after surgery and indicates the initial phase of wound healing. The nurse should measure and document the amount and color of wound drainage and change the dressings as prescribed.
Choice C reason: This is not an indication of a wound infection because crusting along the incision or scab formation is a normal finding in the first 3 days after surgery and indicates the initial phase of wound healing. The nurse should avoid removing or picking at the crusts and keep the wound site clean and dry.
Choice D reason: This is not an indication of a wound infection because bruising around the wound or ecchymosis is a normal finding in the first 3 days after surgery and indicates tissue damage or bleeding from the surgical trauma. The nurse should monitor the size and color of the bruise and apply ice packs as prescribed.
Correct Answer is A
Explanation
Choice A reason: This is an indication that the medication has been effective because hemoglobin is a protein in red blood cells that carries oxygen throughout the body and epoetin alfa is a medication that stimulates red blood cell production in clients who have anemia or low hemoglobin levels due to chronic kidney disease, chemotherapy, or surgery. The normal range of hemoglobin for adults is 12 to 18 g/dL.
Choice B reason: This is not an indication that the medication has been effective because WBC count is a measure of white blood cells that fight infection and epoetin alfa does not affect white blood cell production or function in clients who have anemia or low hemoglobin levels due to chronic kidney disease, chemotherapy, or surgery. The normal range of WBC count for adults is 4,500 to 11,000/mm³.
Choice C reason: This is not an indication that the medication has been effective because PT or prothrombin time is a test that measures how long it takes blood to clot and epoetin alfa does not affect blood clotting or coagulation in clients who have anemia or low hemoglobin levels due to chronic kidney disease, chemotherapy, or surgery. The normal range of PT for adults is 11 to 13.5 seconds.
Choice D reason: This is not an indication that the medication has been effective because total calcium is a measure of calcium in the blood that is important for bone and muscle health and epoetin alfa does not affect calcium levels or metabolism in clients who have anemia or low hemoglobin levels due to chronic kidney disease, chemotherapy, or surgery. The normal range of total calcium for adults is 8.5 to 10.2 mg/dL.
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