A patient is admitted with severe abdominal pain and suspected appendicitis. Based on this scenario, what is the priority nursing action to prevent complications?
Provide analgesics to manage pain effectively.
Perform gentle palpation to assess the degree of tenderness.
Avoid deep palpation and monitor for signs of rupture.
Administer IV fluids to maintain hydration.
The Correct Answer is C
Rationale:
A. Providing analgesics is important for pain management, but it is not the highest priority when appendicitis is suspected. Uncontrolled pain can indicate worsening inflammation or rupture, so assessment and monitoring take precedence before administering strong analgesics.
B. Performing gentle palpation can help assess tenderness, but deep or aggressive palpation can increase the risk of rupturing an inflamed appendix. Assessment should be cautious, prioritizing observation and minimal manipulation.
C. Avoiding deep palpation and monitoring for signs of rupture is the priority action. Appendicitis can progress to perforation, which may lead to peritonitis, sepsis, and shock. Careful monitoring for sudden worsening pain, rebound tenderness, rigidity, fever, or changes in vital signs helps prevent complications and ensures timely surgical intervention.
D. Administering IV fluids is necessary to maintain hydration, especially if the patient is NPO in preparation for surgery. However, it is secondary to the priority of preventing rupture and monitoring for acute changes that indicate an emergent situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Hypertension is not a direct complication of rheumatoid nodules. While rheumatoid arthritis is a systemic inflammatory disease that can increase cardiovascular risk over time, the presence of nodules themselves does not directly cause hypertension and is not the priority concern related to elbow and forearm nodules.
B. Hypoglycemia is not associated with rheumatoid nodules. Although some medications used to treat rheumatoid arthritis (such as corticosteroids) can affect blood glucose levels, they are more commonly linked to hyperglycemia, not hypoglycemia, and this complication is unrelated to nodule formation.
C. Rheumatoid nodules do not increase joint mobility. In fact, rheumatoid arthritis typically causes joint stiffness, deformity, and decreased range of motion. Nodules are firm, non-tender subcutaneous masses that occur over pressure points and do not enhance movement.
D. Rheumatoid nodules commonly develop over pressure points, such as the elbows and forearms. Repeated friction and pressure can lead to skin breakdown, ulceration, and secondary infection, especially in patients with limited mobility or prolonged pressure on affected areas. Preventing skin injury, monitoring for signs of breakdown, and implementing protective measures are key nursing priorities.
Correct Answer is C
Explanation
Rationale:
A. Urine specific gravity reflects the kidney’s ability to concentrate or dilute urine, which can be influenced by hydration status, diuretics, or fluid intake. While it provides information about urine concentration, it is not the most accurate or reliable indicator of overall renal function, especially in chronic or progressive kidney disease.
B. Blood urea nitrogen (BUN) is influenced by many nonrenal factors, including hydration status, protein intake, gastrointestinal bleeding, and liver function. Although BUN may rise with renal impairment, it is less specific for assessing kidney function compared to creatinine.
C. Serum creatinine is the best indicator of renal function because it directly reflects the kidneys’ ability to filter waste products from the blood. Creatinine levels are less affected by diet or hydration and increase when glomerular filtration rate (GFR) declines, making it especially important in monitoring renal involvement (lupus nephritis) in clients with SLE.
D. Serum sodium reflects fluid and electrolyte balance, not kidney filtration ability. Sodium levels may remain normal even in significant renal impairment, making it an unreliable indicator of renal function.
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