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 an appropriate action to take first because pulling the fire alarm panel can alert other staff and personnel about the fire and activate the emergency response system, but it does not address the immediate safety and well-being of the client who is exposed to smoke and flames. The nurse should pull the fire alarm panel after removing the client from the room.
Choice B reason: This is not an appropriate action to take first because obtaining a fire extinguisher can help extinguish or contain the fire and prevent it from spreading to other areas, but it does not address the immediate safety and well-being of the client who is exposed to smoke and flames. The nurse should obtain a fire extinguisher after removing the client from the room.
Choice C reason: This is an appropriate action to take first because removing the client from the room can protect them from smoke inhalation, burns, or injuries and ensure their safety and well-being. The nurse should remove the client from the room as quickly and safely as possible and follow the RACE protocol (Rescue, Alarm, Contain, Extinguish).
Choice D reason: This is not an appropriate action to take first because closing the door to the client's room can help contain the fire and prevent it from spreading to other areas, but it does not address the immediate safety and well-being of the client who is exposed to smoke and flames. The nurse should close the door to the client's room after removing them from the room.
Correct Answer is B
Explanation
Choice A reason: This is not a correct statement because applying the TENS unit at least 6 inches from the actual site of pain can reduce its effectiveness and cause discomfort or irritation to other areas of the skin. The nurse should instruct the client to apply the electrodes directly over or around the site of pain and follow the provider's instructions regarding placement.
Choice B reason: This is a correct statement because adjusting the TENS unit until feeling a tingling sensation can indicate that it is delivering an adequate amount of electrical stimulation to block pain signals from reaching the brain. The nurse should instruct the client to turn on the TENS unit and increase the intensity gradually until feeling a strong but comfortable tingling sensation.
Choice C reason: This is not a correct statement because charging the TENS unit for 2 hours each day can vary depending on the type and model of the device and its battery life. The nurse should instruct the client to follow the manufacturer's instructions regarding charging and maintenance of the TENS unit and check its power level before each use.
Choice D reason: This is not a correct statement because administering a continuous dose of pain medication is not a function of the TENS unit, which does not deliver any drugs or chemicals into the body. The nurse should instruct the client that the TENS unit works by sending mild electrical impulses through electrodes attached to pads that are placed on the skin.
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