The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and a temperature of 102 F. Which of the following is the highest priority?

Administer an antipyretic

Notify the healthcare provider

Prepare to administer an enema.

Continue to monitor the client closely

Answer and Explanation

The Correct Answer is B

peritonitis are present. Treating the underlying cause (perforation) is more urgent than lowering the fever.

B. Notify the healthcare provider: A hard, rigid abdomen with fever indicates possible perforation and peritonitis, which is a medical emergency. The provider must be notified immediately for urgent intervention.

C. Prepare to administer an enema: Enemas are contraindicated in acute diverticulitis due to the risk of perforation.

D. Continue to monitor the client closely: While continued monitoring is always necessary, immediate action (calling the provider) is critical when signs of peritonitis are present.

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Correct Answer is B

Explanation

A. "This procedure will cure my liver disease.": Paracentesis does not cure cirrhosis; it only helps manage complications.

B. "This procedure will remove fluid from my abdomen.": The primary purpose of paracentesis is to drain ascitic fluid and relieve abdominal distention, discomfort, and respiratory compromise.

C. "This procedure will help lower my ammonia levels.": Ammonia levels are managed through lactulose therapy and dietary modifications, not paracentesis.

D. "This procedure will help reduce my risk of infection.": While paracentesis may be performed to obtain fluid for infection evaluation (spontaneous bacterial peritonitis), it does not inherently reduce infection risk.

A. Avoid drawing blood from the affected extremity B. Auscultate the fistula for the sound of a bruit C. Palpate the site to identify the presence of a thrill D. Irrigate the fistula with saline to maintain patency E. Keep the fistula clamped until ready to perform dialysis

Correct Answer is ["A","B","C"]

Explanation

A. Avoid drawing blood from the affected extremity: Blood draws, IVs, and BP measurements should never be done on the fistula arm to prevent damage and thrombosis.

B. Auscultate the fistula for the sound of a bruit: A bruit (whooshing sound) confirms blood flow through the fistula, indicating patency.

C. Palpate the site to identify the presence of a thrill: A thrill (vibration) should be felt over the fistula. Absence may indicate clotting or failure.

D. Irrigate the fistula with saline to maintain patency: A fistula is never irrigated. Only dialysis staff should access it.

E. Keep the fistula clamped until ready to perform dialysis: AV fistulas are not clamped. Clamping could obstruct blood flow.

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The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and a temperature of 102 F. Which of the following is the highest priority?

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Naxlex Comprehensive Predictor Exams

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