Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse recognizes that the client has

evidenced by

. (Finding)

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

• Appendicitis: The sudden onset of right lower quadrant pain, elevated WBC count, low-grade fever, and CT scan findings of a dilated appendix and fat stranding point to acute appendicitis. This is a common surgical emergency that requires prompt diagnosis and intervention.

• Computed tomography (CT) scan results: The CT scan is the most definitive diagnostic tool for appendicitis. A 7 mm dilated appendix with fat stranding is classic radiologic evidence of appendiceal inflammation and supports surgical consultation.

• White blood cell count: The client’s WBC is 16,000/mm³, which is elevated and indicative of a systemic inflammatory response, commonly seen in appendicitis. Leukocytosis helps confirm infection and supports imaging findings.

Rationale for Incorrect Options:

• Gastroenteritis: Typically presents with diffuse abdominal cramping, diarrhea, and vomiting, often related to foodborne illness or viral infection. The absence of diarrhea and the presence of localized RLQ pain make this diagnosis unlikely.

• Peptic Ulcer Disease: Presents with epigastric pain, often related to meals or NSAID use. Pain is typically described as burning or gnawing, and not associated with right lower quadrant tenderness or leukocytosis, which are more consistent with appendicitis.

• Red blood cells count: The RBC count is within normal limits and does not aid in diagnosing appendicitis. It may be more relevant in cases of anemia, bleeding, or systemic illness but is not diagnostic in this scenario.

• Temperature: 100.8° F (38.2° C): A low-grade fever supports the presence of inflammation or infection. While nonspecific, it adds clinical weight to the suspicion of appendicitis when correlated with WBC elevation and CT results.

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Correct Answer is B

Explanation

A. Advance from clear liquids as tolerated: Resuming oral intake is important for recovery but can be delayed until critical tasks like infection prevention are addressed immediately after surgery.

B. Cefazolin 1 gram IV every 6 hours: Administering prophylactic antibiotics like cefazolin early after surgery is crucial to prevent postoperative infections, making this the highest priority action upon admission.

C. Complete blood cell count (CBC) in AM: A CBC is important for monitoring postoperative recovery but is a scheduled task for later and does not need to be prioritized over immediate interventions.

D. Straight catheterization if unable to void: Monitoring for urinary retention is necessary, but catheterization is only performed if the client cannot void after a certain period, making it a lower immediate priority.

A. Cleanse the perineal area in circular motion after voiding. B. Drink large amounts of fluids before bedtime. C. Empty the bladder before and after sexual intercourse. D. Hold urine for at least 10 minutes to dilute bacteria.

Correct Answer is C

Explanation

A. Cleanse the perineal area in circular motion after voiding: Cleaning should be done from front to back, not in a circular motion, to prevent introducing bacteria from the anal area to the urethra.

B. Drink large amounts of fluids before bedtime: Drinking large amounts before bed can lead to bladder distention and nighttime urgency, which may not effectively prevent infection and can disrupt sleep.

C. Empty the bladder before and after sexual intercourse: Voiding before and after intercourse helps flush out bacteria introduced into the urethra during sexual activity, significantly reducing the risk of UTI.

D. Hold urine for at least 10 minutes to dilute bacteria: Holding urine encourages bacterial growth by allowing urine to remain stagnant in the bladder longer, increasing the risk of infection rather than preventing it.

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Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that the client has ____ evidenced by ____. (Finding)

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Naxlex Comprehensive Predictor Exams

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Correct Answer is B

Explanation

The nurse is teaching a female client about preventive measures for urinary tract infections (UTI). Which information should the nurse include?

Correct Answer is C

Explanation

When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the UAP?

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Patient Data Which should the nurse immediately do? Select all that apply.

A client who fell and broke a wrist is admitted for 24 hour observation after emergency orthopedic surgery. The healthcare provider prescribes discharge in the morning. Which finding(s) should the nurse use to evaluate the client's status for discharge from the hospital? Select all that apply.

A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

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The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome should the nurse include in the plan of care for this client?

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse recognizes that the client has

evidenced by

. (Finding)