The nurse is caring for a client who presents with acute appendicitis:

Exhibits

Select all that apply?

Creatinine, 0.9 mg/dL

White blood cell count, 11,500 mm"

BUN 26 mg/dL.

Reports of pain increasing while coughing

Potassium 3.3 mEq/L

Nausea and vomiting

Answer and Explanation

Correct Answer : B,C,D,E

Choice A rationale: This is a normal value, indicating normal renal function. The client does not have any signs of kidney damage or impairment.

Choice B rationale: This is an elevated value, indicating an infection or inflammation in the body. Acute appendicitis is a common cause of increased white blood cells, as the appendix becomes inflamed and infected. This finding requires immediate follow-up to monitor the client's condition and prevent complications such as perforation or peritonitis.

Choice C rationale: This is a high value, indicating impaired renal function or dehydration. The client may have decreased urine output due to vomiting and fluid loss, or may have underlying kidney problems. This finding requires immediate follow-up to assess the client's hydration status and renal function, and to provide appropriate fluid and electrolyte replacement.

Choice D rationale: This is a sign of peritoneal irritation, which may indicate that the appendix has ruptured or is close to rupturing. This is a medical emergency that requires immediate surgical intervention to remove the appendix and prevent sepsis and shock.

Choice E rationale: This is a low value, indicating hypokalemia or low potassium levels in the blood. The client may have lost potassium due to vomiting and fluid loss, or may have underlying electrolyte imbalances. This finding requires immediate follow-up to assess the client's cardiac function and muscle strength, and to provide appropriate potassium supplementation.

Choice F rationale: These are common symptoms of acute appendicitis, as the inflammation and infection of the appendix cause irritation of the gastrointestinal tract. These symptoms do not require immediate follow-up, but they should be managed with antiemetics and fluids to prevent dehydration and electrolyte imbalances.

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Correct Answer is C

Explanation

Choice A rationale: A client with nausea, vomiting, and abdominal pain may have gastroenteritis, food poisoning, or appendicitis, which are not directly related to the eyes.

Choice B rationale: A client with chest tightness and heartburn may have gastroesophageal reflux disease (GERD), angina, or myocardial infarction (MI), which are also not associated with the eyes.

Choice C rationale: A client with facial drooping and left-sided weakness may have a stroke, which is a medical emergency that requires immediate attention. An eye examination can help detect signs of stroke, such as pupil asymmetry, visual field defects, or eye movement abnormalities. A stroke can cause permanent brain damage or death if not treated promptly.

Choice D rationale: A client with fatigue, fever, and productive cough may have a respiratory infection, such as pneumonia or tuberculosis, which are unlikely to affect the eyes unless there is a systemic complication.

A. a Gloves should be worn during direct contact with the client's skin. B. No precautions in addition to standard precautions are necessary. C. Handwashing is required before and after contact with the client. D. A mask should be worn by anyone entering the client's room.

Correct Answer is A

Explanation

Choice A rationale: Gloves should be worn during direct contact with the client's skin. This is a standard precaution that applies to all clients, but especially to those with infectious diseases that can be transmitted through contact. Secondary syphilis is highly contagious and can be spread through direct contact with the skin lesions or mucous

membranes of an infected person.

Choice B rationale: This is incorrect because secondary syphilis requires more than standard precautions to prevent transmission.

Choice C rationale: This is incorrect because handwashing is a basic component of standard precautions and is not sufficient to prevent the spread of syphilis.

Choice D rationale: This is incorrect because a mask is not necessary for contact precautions, unless the client has respiratory symptoms or is undergoing aerosol- generating procedures.

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The nurse is caring for a client who presents with acute appendicitis: Exhibits Select all that apply?

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The nurse is caring for a client who presents with acute appendicitis:

Exhibits

Select all that apply?