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 D
Explanation
Choice A reason: This is not an expected sensation during injection of the contrast medium because numbness in the fingertips can indicate peripheral nerve damage or ischemia, which are rare but serious complications of cardiac catheterization. The nurse should assess the client's peripheral pulses, capillary refill, and sensation and report any abnormalities.
Choice B reason: This is not an expected sensation during injection of the contrast medium because pain in the jawline can indicate angina or myocardial infarction, which are rare but serious complications of cardiac catheterization. The nurse should monitor the client's vital signs, electrocardiogram, and chest pain and report any changes.
Choice C reason: This is not an expected sensation during injection of the contrast medium because urge to urinate can indicate bladder distension or urinary tract infection, which are unrelated to cardiac catheterization. The nurse should encourage the client to empty their bladder before the procedure and check for urinary retention or dysuria after the procedure.
Choice D reason: This is an expected sensation during injection of the contrast medium because feeling of heat can occur as a result of vasodilation caused by the contrast medium, which increases blood flow to the skin and mucous membranes. The nurse should inform the client that this sensation is normal and temporary and will subside within a few minutes.
Correct Answer is B
Explanation
Choice A reason: This is not a food that the nurse should recommend because oatmeal is high in fiber and phytates, which are compounds that can bind to iron and reduce its absorption in the gastrointestinal tract. The nurse should advise the client to avoid consuming foods high in fiber or phytates within 2 hours before or after taking ferrous sulfate.
Choice B reason: This is a food that the nurse should recommend because raw oranges are high in vitamin C, which is an antioxidant that can enhance iron absorption by reducing it to its more soluble form. The nurse should advise the client to consume foods high in vitamin C, such as citrus fruits, tomatoes, or peppers, along with ferrous sulfate.
Choice C reason: This is not a food that the nurse should recommend because cheese is high in calcium and casein, which are substances that can interfere with iron absorption by forming insoluble complexes with it. The nurse should advise the client to avoid consuming foods high in calcium or casein, such as dairy products, eggs, or soybeans, within 2 hours before or after taking ferrous sulfate.
Choice D reason: This is not a food that the nurse should recommend because baked potatoes are high in starch and oxalates, which are compounds that can inhibit iron absorption by forming insoluble salts with it. The nurse should advise the client to avoid consuming foods high in starch or oxalates, such as potatoes, spinach, or rhubarb, within 2 hours before or after taking ferrous sulfate.
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