The nurse is receiving morning report on several clients with diseases causing inflammation. What client is the priority for the nurse to assess first?
A client with cholecystitis who is nauseous when they eat fatty foods.
A client with bronchitis who has a productive cough.
A client with appendicitis who has a rigid abdomen and a temperature.
A client with nephritis and a urine output of 30mL/hour.
The Correct Answer is C
A. Nausea with fatty foods is expected in cholecystitis and does not indicate immediate life-threatening complications.
B. A productive cough in bronchitis requires monitoring and supportive care, but it is not the most urgent concern.
C. Rigid abdomen and fever in appendicitis indicate peritonitis, a surgical emergency. This client is at highest risk for sepsis and requires immediate assessment and intervention.
D. Urine output of 30 mL/hour is low but not immediately life-threatening compared to peritonitis; it requires monitoring and possible intervention but is less urgent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E","F"]
Explanation
A. Enemas and laxatives are contraindicated because they can increase intra-abdominal pressure and risk of appendix rupture.
B. IV fluids restore hydration, and antibiotics help prevent infection.
C. Consent must be signed before surgery.
D. Client should remain NPO to reduce aspiration risk during anesthesia.
E. Monitoring urine output is essential for assessing hydration and kidney perfusion.
F. IV pain medication is appropriate for pain control pre- and postoperatively.
Correct Answer is C
Explanation
A. A family history of syncope is not a risk factor for acute glomerulonephritis.
B. Sexual activity is not a common contributing factor to glomerulonephritis.
C. Acute glomerulonephritis often develops 1–2 weeks after a streptococcal infection such as strep throat or impetigo. Asking about recent illness helps determine if a prior infection contributed to the condition.
D. Low blood pressure is not typically associated with glomerulonephritis; in fact, hypertension is more common due to fluid retention.
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