a nurse is admitting a client who has suspected appendicitis which of the following findings should the nurse report to the provider immediately

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?

A. Distended, board-like abdomen
B. WBC count of 15,000/mm3
C. Rebound tenderness over McBurney's point
D. Temperature of 37.3°C (99.1°F)

Correct answer: A

Rationale: A distended, board-like abdomen should be reported to the provider immediately because it indicates peritonitis, a serious complication of appendicitis resulting from a ruptured appendix. Option B, an elevated WBC count, may indicate infection but is not as urgent as a board-like abdomen. Option C, rebound tenderness over McBurney's point, is a classic sign of appendicitis but does not indicate immediate life-threatening complications. Option D, a slightly elevated temperature, is not as concerning as a distended, board-like abdomen.

2. What symptoms are expected in a patient with compartment syndrome?

A. Unrelieved pain, pallor, and pulselessness
B. Localized swelling and numbness
C. Fever and infection
D. Weakness and fatigue

Correct answer: A

Rationale: In a patient with compartment syndrome, the key symptoms include unrelieved pain, pallor, and pulselessness. These symptoms indicate reduced circulation in the affected compartment. Choice B is incorrect as localized swelling and numbness are not typically associated with compartment syndrome. Choice C is incorrect as fever and infection are not primary symptoms of compartment syndrome. Choice D is incorrect as weakness and fatigue are not typically seen in compartment syndrome.

3. What is the priority action for a patient experiencing chest pain from acute coronary syndrome?

A. Administer sublingual nitroglycerin
B. Obtain IV access
C. Check the patient's cardiac enzymes
D. Administer aspirin

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. Nitroglycerin helps relieve chest pain by dilating blood vessels and improving blood flow to the heart, which is crucial in managing acute coronary syndrome. While obtaining IV access and checking cardiac enzymes are important steps in the assessment and management of acute coronary syndrome, administering nitroglycerin takes precedence to alleviate symptoms and reduce cardiac tissue damage. Administering aspirin is also essential in the treatment of acute coronary syndrome, but it is not the immediate priority in this scenario.

4. What is the purpose of an escharotomy?

A. To relieve pressure and improve circulation in burn injuries
B. To reduce pain in the affected area
C. To remove necrotic tissue from a wound
D. To prevent infection from spreading

Correct answer: A

Rationale: An escharotomy is performed to relieve pressure and improve circulation in areas affected by deep burns. This procedure helps prevent complications such as compartment syndrome by releasing the constricting eschar. Choice B is incorrect because while pain relief may be a secondary outcome of the procedure, the primary purpose is to address pressure and circulation issues. Choice C is incorrect as an escharotomy specifically focuses on releasing pressure, not removing necrotic tissue. Choice D is incorrect as the primary goal of an escharotomy is not to prevent infection but rather to address the immediate issues related to deep burn injuries.

5. What is the priority action for a patient experiencing chest pain from acute coronary syndrome?

A. Administer sublingual nitroglycerin
B. Administer aspirin
C. Obtain IV access
D. Check cardiac enzymes

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. This medication helps to dilate the blood vessels, reduce the workload on the heart, and improve blood flow to the heart muscle, providing immediate relief for chest pain in acute coronary syndrome. Administering aspirin is also crucial in the early management of acute coronary syndrome to prevent further clot formation. However, in terms of immediate symptom relief, nitroglycerin takes precedence over aspirin. Obtaining IV access is important for administering medications and fluids but is not the priority over providing immediate relief for chest pain. Checking cardiac enzymes is essential for diagnosing acute coronary syndrome but is not the immediate priority when a patient is experiencing chest pain.