A. Preoperative chest x-ray report is not available: While a chest x-ray may provide useful baseline information, the absence of this report is not immediately life-threatening. The surgery could still proceed safely if the client is otherwise stable.

B. Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L): A potassium level below the normal range places the client at high risk for life-threatening cardiac arrhythmias under anesthesia. This requires immediate correction before proceeding with surgery.

C. Surgical consent form is not signed: A missing consent form is legally significant and must be addressed before surgery, but it does not pose an immediate physiological threat to the client. It can be corrected once the provider discusses the procedure with the client.

D. Client's pulse oximeter reading is 96%: An oxygen saturation of 96% is within the acceptable range and does not indicate acute hypoxemia. While it should be monitored, this value does not represent an urgent or life-threatening concern.

Rationale for Correct Choices:

• Appendicitis: The client presents with acute onset right lower quadrant pain, nausea, vomiting, fever, and elevated WBC, all classic signs of appendicitis. The CT scan confirms a dilated appendix with fat stranding, which is a definitive diagnostic finding.

• Computed tomography (CT) scan results: Imaging confirms the diagnosis by showing a 7 mm dilated appendix with fat stranding, which directly identifies appendiceal inflammation.

• White blood cell count (WBC): The elevated WBC of 16,000/mm³ indicates an inflammatory or infectious process, supporting the diagnosis of appendicitis.

Rationale for Incorrect Choices:

• Cholecystitis: Typically presents with right upper quadrant pain, often radiating to the shoulder, and may be associated with jaundice. This client’s pain is localized to the right lower quadrant, making cholecystitis unlikely.

• Gastroenteritis: Usually causes diffuse abdominal pain, diarrhea, and generalized cramping. The patient has localized right lower quadrant pain and no diarrhea, so gastroenteritis is less likely.

• Fever: While the client does have a low-grade fever (100.8°F), this is a non-specific symptom that can be present in a variety of conditions, including gastroenteritis and cholecystitis. It is not as specific or as definitive as the CT scan or the WBC count.

• Nausea and vomiting: These are common but nonspecific symptoms present in many gastrointestinal conditions and cannot solely confirm appendicitis.

• Constipation: The client reports normal bowel movements; constipation is not present and does not support the diagnosis of appendicitis.

A. Bile stained emesis: Vomiting bile can occur in biliary obstruction and gallbladder disease. While concerning, it is not immediately life-threatening. Symptom management and monitoring are important, but it does not require the most urgent provider notification.

B. Radiating, sharp pain in right shoulder: Referred pain to the shoulder is a common feature of gallbladder inflammation or obstruction due to diaphragmatic irritation. Although uncomfortable, it is expected in cholelithiasis and does not indicate a critical complication.

C. Clay colored stool: Pale or clay-colored stool reflects a lack of bile reaching the intestines, which confirms obstruction of the bile duct. This is significant but expected in jaundice related to cholelithiasis and not an acute emergency.

D. Distended, hard, and rigid abdomen: A rigid, board-like abdomen indicates possible peritonitis, perforation, or severe intra-abdominal infection. This is a life-threatening complication requiring immediate reporting and urgent intervention.

A. Demonstrate the use of visual scanning during meals to the client and family: Visual scanning helps clients with perceptual deficits from CVA compensate for neglect of one side of their visual field. Teaching this strategy empowers both the client and family to promote independence and improve nutritional intake during meals.

B. Suggest that the family bring foods from home that the client enjoys eating: While familiar foods may encourage eating, the problem is not appetite but visual perception. Bringing food from home does not address the underlying deficit causing incomplete meal consumption.

C. Explain that weight loss will be reversed after the acute phase of the stroke has ended: Weight loss may not automatically improve, as visual perception deficits can persist long after the acute phase. False reassurance overlooks the real need for compensatory strategies.

D. Encourage the family to offer to feed the client when she does not eat her entire meal: Feeding the client when unnecessary reduces independence and may create frustration. The priority is to teach adaptive techniques that promote self-feeding.

A. Upper midabdominal pain described as gnawing and burning: This is the hallmark symptom of peptic ulcer disease. The pain often occurs when the stomach is empty, is relieved by food or antacids, and has a chronic, burning quality that is strongly associated with ulcer formation.

B. Severe abdominal cramps and diarrhea after eating spicy foods: Spicy foods may irritate the stomach but they do not directly cause PUD. Cramping and diarrhea are more characteristic of gastrointestinal infections or irritable bowel disorders rather than PUD.

C. Marked loss of weight and appetite over the last 3 or 4 months: While weight loss and anorexia can be seen with advanced PUD, they are not specific to the disease and may occur in many chronic illnesses, making them less diagnostic compared to ulcer pain.

D. Frequent use of chewable and liquid antacids for indigestion: The use of antacids reflects attempts to relieve gastrointestinal discomfort but does not in itself confirm the diagnosis of PUD. Many non-ulcer conditions such as GERD or gastritis can cause frequent antacid use.

A. Visualize the abdominal incision: The client’s description strongly suggests wound dehiscence or evisceration, which is a surgical emergency. The nurse’s immediate action should be to inspect the incision to confirm the situation before taking further interventions.

B. Obtain sterile towels soaked in saline: Applying sterile saline dressings is critical once evisceration is confirmed to prevent tissue drying and infection. However, this should follow visualization of the incision to validate the client’s report and guide correct intervention.

C. Assure the client that such feelings occur with wound infections: Providing reassurance delays urgent assessment and intervention. Evisceration is not a sensation of infection and requires immediate action rather than reassurance.

D. Notify the healthcare provider: The surgeon must be informed quickly if evisceration is confirmed, but assessment should precede notification. Prompt visualization ensures the nurse communicates accurate and timely findings to guide emergency treatment.

A. A 70-year-old fair-skinned client who works as a secretary: Fair skin increases risk, but a primarily indoor occupation minimizes long-term UV exposure. This client is at increased risk compared to darker-skinned individuals but not the highest overall.

B. A 25-year-old dark-skinned client whose mother had skin cancer: A positive family history raises susceptibility, but darker skin provides protection against UV damage. This combination increases risk but is not as high as prolonged occupational sun exposure in fair-skinned individuals.

C. A 65-year-old fair-skinned client who is a construction worker: Fair skin plus decades of outdoor occupational sun exposure creates the highest cumulative risk for skin cancer. Chronic UV exposure is the leading preventable cause, making this the most concerning.

D. A 16-year-old dark-skinned client who tans in tanning beds once a week: Tanning beds significantly increase melanoma risk, but younger age and protective skin pigmentation reduce cumulative lifetime exposure so far.

Calculation:

Total volume to infuse = 100 mL.

Infusion time = 30 minutes

= 30 minutes / 60 minutes/hour

= 0.5 hours.

• Calculate the infusion rate in milliliters per hour (mL/hr).

Infusion rate (mL/hr) = Total volume (mL) / Total time (hr)

= 100 mL / 0.5 hr

= 200 mL/hr.

A. Assess for perineal itching, erythema, and excoriation: These findings are more consistent with a fungal or irritant-related infection, not the primary concern in a client presenting with dysuria after recent sexual exposure. While useful, this does not immediately confirm the underlying cause.

B. Obtain a specimen of urethral drainage for culture: Burning with urination after unprotected intercourse raises suspicion for a sexually transmitted infection such as gonorrhea or chlamydia. Obtaining a specimen allows accurate diagnosis and guides targeted antimicrobial therapy.

C. Observe the perineal area for a chancroid-like lesion: Chancroid and syphilis typically present with ulcerative lesions, not isolated dysuria. While a physical exam is important, it will not confirm the cause as reliably as a culture for organisms that commonly cause urethritis.

D. Identify all sexual partners in the last four days: Partner notification is a crucial step after a diagnosis of STI is established, but it is premature at this stage. Confirmation of infection through culture should occur before implementing public health reporting or partner tracing.

A. Select a protein-rich food daily: In acute glomerulonephritis, excessive protein intake can worsen azotemia because damaged kidneys cannot effectively excrete protein byproducts. Protein is usually restricted depending on renal function and degree of proteinuria.

B. Eat high-potassium foods: Potassium levels often rise in kidney disorders due to impaired excretion, increasing the risk for hyperkalemia and dangerous arrhythmias. Clients should not be encouraged to consume high-potassium foods unless specifically prescribed.

C. Avoid foods high in carbohydrates: Carbohydrates are not restricted in AGN. In fact, adequate carbohydrate intake can provide calories while minimizing the breakdown of body proteins, which helps reduce nitrogenous waste accumulation.

D. Restrict sodium intake: Sodium restriction helps control edema and hypertension, both common complications of acute glomerulonephritis. Limiting salt intake is the key dietary recommendation to reduce fluid overload and protect renal function during the acute phase.