The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and a temperature of 102 F. Which of the following is the highest priority?

Administer an antipyretic

Notify the healthcare provider

Prepare to administer an enema.

Continue to monitor the client closely

Answer and Explanation

The Correct Answer is B

peritonitis are present. Treating the underlying cause (perforation) is more urgent than lowering the fever.

B. Notify the healthcare provider: A hard, rigid abdomen with fever indicates possible perforation and peritonitis, which is a medical emergency. The provider must be notified immediately for urgent intervention.

C. Prepare to administer an enema: Enemas are contraindicated in acute diverticulitis due to the risk of perforation.

D. Continue to monitor the client closely: While continued monitoring is always necessary, immediate action (calling the provider) is critical when signs of peritonitis are present.

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Correct Answer is A

Explanation

A. Only use a soft-bristle toothbrush: Clients with thrombocytopenia are at risk for bleeding, including gum bleeding. Using a soft-bristle toothbrush minimizes trauma to the gums and reduces the risk of bleeding.

B. Apply an ice pack over a bleeding wound: While ice can help constrict blood vessels and reduce minor bleeding, it is not the primary preventative measure for thrombocytopenia-related bleeding.

C. Use a floss pick instead of the floss string to clean between teeth: A floss pick may still cause gum trauma. It is recommended to use a soft flossing technique or avoid flossing if platelet counts are extremely low.

D. Wear sleeveless or short-sleeved shirts and shorts to better visualize any skin issues: While monitoring for petechiae or bruising is important, it does not actively prevent bleeding complications.

A. Avoid drawing blood from the affected extremity B. Auscultate the fistula for the sound of a bruit C. Palpate the site to identify the presence of a thrill D. Irrigate the fistula with saline to maintain patency E. Keep the fistula clamped until ready to perform dialysis

Correct Answer is ["A","B","C"]

Explanation

A. Avoid drawing blood from the affected extremity: Blood draws, IVs, and BP measurements should never be done on the fistula arm to prevent damage and thrombosis.

B. Auscultate the fistula for the sound of a bruit: A bruit (whooshing sound) confirms blood flow through the fistula, indicating patency.

C. Palpate the site to identify the presence of a thrill: A thrill (vibration) should be felt over the fistula. Absence may indicate clotting or failure.

D. Irrigate the fistula with saline to maintain patency: A fistula is never irrigated. Only dialysis staff should access it.

E. Keep the fistula clamped until ready to perform dialysis: AV fistulas are not clamped. Clamping could obstruct blood flow.

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The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and a temperature of 102 F. Which of the following is the highest priority?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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